Risk Factors of Gestational Diabetes Mellitus in Gombak District, Selangor A Case-Control Study

By Dr Siti Rohana Saad MBBS (MAHE), MPH (UM) Family Health Development Unit, Public Health Division, Selangor State Health Department

Outline
Introduction Problem Statement Rationale of Study Methods Results Discussion Recommendations Conclusion
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Introduction
Gestational Diabetes Mellitus (GDM)
Definition 1,2,3 Represents most common metabolic complication during pregnancy; early manifestation of type 2 diabetes 4,5 Certain characteristics (risk factors) in the women may predispose to development of GDM during pregnancy 3,6

Problem statement
Prevalence of GDM varies from 1-14% between countries1,4,6; varies in direct proportion to prevalence of type 2 diabetes in a given population7 In Malaysia
Diabetes prevalence (among adult 30yrs of age) had increased from 8.3% to 14.9% (1996 to 2006)8 Diabetes admission based on type of diabetes (19942004): GDM represent 30% of total admission9 GDM prevalence: 1993 (UMMC):12.7%10 2001 (HUKM): 24.9%11 2003 (Alor Star): 18.3%21
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Problem statement (cont)

GDM was the cause for 90% of all pregnancies complicated by diabetes22 Associated with maternal and foetal morbidity 4,5 High proportion (>50%) have GDM in the subsequent pregnancy23 Associated with an increased risk of subsequent type 2 diabetes mellitus.
approximately 50% of the women with GDM progressed to DM within five years duration7 35-60% of women developed type 2 diabetes within 10 years after being diagnosed with GDM3
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Rationale of Study
Literature search done showed scarcity of published article on study done in relation to GDM in this region Previous study done mostly at referral and specialised unit results may not represent the true picture of the disease Identification of GDM risks factors will provide information in strengthening public health measures & prevent complications (maternal, foetal, development of overt diabetes & cardiovascular)
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Study Objectives
General Objectives To determine the risk factors of GDM in Gombak District, Selangor. Specific Objectives 1. To describe socio-demographic and obstetric characteristics of pregnant women with GDM. 2. To determine the magnitude of association between the socio-demographic and obstetric characteristics with development of GDM 3. To determine the independent risk factors of GDM among pregnant women in Gombak District, Selangor
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Methods
Study design Case control study (1:1) Study duration June 2007- February 2008 Study population Pregnant women who had antenatal visits at MCH clinics of Gombak District, Selangor. Case Pregnant women diagnosed with GDM using 75gm OGTT : 2hpp plasma glucose level 7.8 mmol/l Control Pregnant women without GDM sampled from the same clinic on the same day each case was identified
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Location of Study Area - Gombak District of Selangor State

Total land area 796,084 ha

Land area 65,008 ha

Methods of data collection

1. Face to face interview
2. Weight measurement
Using weighing machine existing in the clinic

Single interviewer R/V of antenatal Pre-tested standardised 3. records structured questionnaire Secondary data Socio-demographic BMI, excessive weight gain, FBS, characteristics 2-HPP blood Obstetric sugar, Urine sugar Additional information characteristics Medical history, Past-obstetric Family History history Countercheck information Present Obstetric history
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Variables
Dependent variable
Gestational Diabetes Mellitus Obstetric characteristics 1. Past-obstetric history
LSCS, Big baby, GDM, IUD, NND, Abortion, Congenital defect, Prematurity, Gest. Hypertension

Independent variables
Socio-demographic
Age, ethnicity, educational level, household income.

Life style
BMI, excessive wt gain, Hb level

2.

Present obstetric history

Glycosuria, PV discharge, Pruritus vulvae, UTI, Gest. Hypertension
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F/H of DM

Factors associated with GDM

Characteristics Maternal Age (yrs) < 25 25 35 >35 < 2000 2000 < 18.5 18.5-24.9 25.0-29.9 30.0 Non-GDM (n-337) 93 (27.6%) 214(63.5%) 30(8.9%) 162 (48.1%) 175 (51.9%) 49 (14.5%) 180 (53.4%) 77 (22.9%) 31 (9.2%) GDM (n-337) 35 (10.4%) 200 (59.3%) 102(30.3%) 134 (39.8%) 203 (60.2%) 17 (5.1%) 144 (42.7%) 90 (26.7%) 86 (25.5%) Crude OR (95% CI) Ref 2.48 (1.61, 3.83) 9.03 (5.15, 15.86) Ref 1.40 (1.03 , 1.90) Ref 2.31 (1.27 , 4.18) 3.37 (1.79 , 6.33) 7.99 (4.02 , 15.91)

Income (RM) Prepregnant BMI (Kg/m)

Factors Associated with GDM

Characteristics Non-GDM (n-337)
310 (92.0%) 27 (8.0%) 291 (86.4%) 46 (13.6%) 333 (98.8%) 4 (1.2%) 335 (99.4%) 2 (0.6%)

GDM (n-337)
289 (85.8%) 48 (14.2%) 262 (77.7%) 75 (22.3%) 312 (92.6%) 25 (7.4%) 323 (95.8%) 14 (4.2%)

Crude OR (95% CI)

Ref 1.91 (1.16 , 3.14) Ref 1.81 (1.21 , 2.71) Ref 6.67 (2.30 , 19.38) Ref 7.26 (1.64 , 32.20)

P/H LSCS

No Yes No Yes No Yes No Yes

P/H Abortion P/H of Big baby H/O Glycosuria

Factors Associated with GDM

Characteristics Non-GDM (n-337) 208 (61.7%) 129 (38.3%) 322 (95.5%) 15 (4.5%) 291 (86.4%) 46 (13.6%) 297 (88.1%) 40 (11.9%) GDM (n-337) 112 (33.2%) 225 (66.8%) 298 (88.4%) 39 (11.6%) 264(78.3%) 73 (21.7%) 278 (82.5%) 59 (17.5%) Crude OR 95% CI Ref 3.21 (2.35, 4.40) Ref 3.24 (2.36, 4.44) Ref 1.75 (1.17, 2.62) Ref 1.58 (1.02, 2.43)

H/O excess. Weight gain

No Yes No Yes No Yes No Yes

H/O Gestational Hypertension H/O PV discharge H/O Pruritus vulvae

Independent risk factors for GDM

Characteristics
Maternal age (Years) < 25 25 34 35 < 18.5 18.5-24.99 25.0-29.99 30.0 <2000 2000 No Yes

Adjusted OR (95% CI)

Ref 2.03 (1.22 , 3.37) 11.95 (6.13, 23.29) Ref 1.18 (0.59 , 2.35) 1.37 (0.66 , 2.85) 3.71 (1.38, 6.76) Ref 1.49 (1.02 , 2.18) Ref 3.62 (2.44, 5.36)

Pre pregnant BMI (kg/m2)

Household Income /month (RM) Family History of DM

Independent risk factors for GDM

Characteristics
P/H of GDM No Yes No Yes No Yes No Yes

Adjusted OR (95% CI)

Ref 3.41 (1.37 , 8.51) Ref 5.83 (1.77 , 19.20) Ref 2.25 (1.39 , 3.65) Ref 3.95 (2.69, 5.80)

P/H of Big baby

H/O Exc. vaginal discharge H/O Excessive weight gain

Discussion
Socio-demographic Maternal age 25 yrs and the odds increases as age 35 yrs with OR and 95% CI of 2.48 (1.61, 3.83) & 9.03 (5.15, 15.86) respectively 11,13, 15, 16, 19 Gravidity the odds was 2.56 x higher in multigravid women (1.66, 3.94) 13, 16 Economic status The odds was 1.40x higher in higher household income supported by other study16 but other studies 14, 15 were contradicting Lifestyle Pre pregnant BMI odds as BMI , highest in obesity (7.99: 4.02, 15.91) 13, 15, 16, 19 Excessive weight gain OR: 3.21 (2.36, 4.44)18
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Discussion (cont)
Obstetric Characteristics
Previous H/O GDM 11, 17 Previous H/O Big baby 15, 16 Previous H/O LSCS 16 Previous H/O Abortions 11, 15, 16 H/O glycosuria 15 H/O gestational hypertension 15, 20 H/O excessive vaginal discharge

Independent risk factors

This study confirms results from the previous studies that risk factors for GDM are: Maternal age 11,13, 15, 16, 19; Pre pregnant obesity 13, 15, 16, 19; Excessive weight gain 18; Family history of DM 15, 17, 18, 19; Previous history of GDM 11,17; Previous history of big baby 15, 16 Higher income16 and excessive vaginal discharge

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Strength of study
Case and control group were comparable since they came from the same population pregnant women from the same clinic High responds rate as the respondents were not put into any risk and not subjected to any inconvenience of OGTT Study was done in Government Maternal and Child Health Clinics which covers almost 80% of antenatal population of the - Community Based

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Limitation
The study design temporality cannot be ascertained Information bias
Respondents are subjected to recall bias Interviewer bias in getting information Steps taken: compared information from the antenatal records Single interviewer reduced inter observer bias

Selection bias
In selecting controls and cases based on presence of risk factor/s

Measurement bias
Weight measurement not properly done or weighing machine not properly calibrated In defining cases false positive/ negative result of plasma glucose level

Confounding bias
Confounders are statistically controlled by subjecting variables to multiple logistic regression

Generalizability
Result of study can only be generalised to the antenatal population attending the government health clinics
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Recommendation
Having GDM registry at periphery and the central level Considering maternal age 25 yrs, exc. vaginal discharge for OGTT Concerted effort, multidisciplinary approach in preventing and managing GDM Antenatal services Pre marital health care programme Strengthening of family planning programme Strengthening the promotive and preventive health care in tackling the lifestyle factors associated with GDM Policy on universal screening of GDM using GCT
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Conclusion
Development of GDM is associated with presence of risk factors Strong and significant association between GDM and the identified independent risk factors in this study warrants serious attention in its prevention and management prior to and throughout pregnancy Screening of GDM using risk criteria should consider Maternal age 25 yrs Presence of excessive vaginal discharge in index pregnancy

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References
1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2009 January;32 (supplement 1):88-90. 2. Perkins JM, Dunn JP, Jagasia SM. Perspectives in Gestational Diabetes Mellitus: A Review of Screening, Diagnosis, and Treatment. Clinical Diabetes 2007;25(2):57-62. 3. Metzger BE, Coustan DR. Summary and recommendations of the Fourth International WorkshopConference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care. 1998 Aug;21 Suppl 2:B161-7. 4. Cianni GD, Seghieri G, Lencioni C, Cuccuru I, Anichini R, Bellis AD, et al. Normal Glucose Tolerance and Gestational Diabetes Mellitus. Diabetes Care. 2007;30(7):1783-8. 5. Mumtaz M. Gestational Diabetes Mellitus. Malaysian Journal of Medical Sceince. 2000 January;7(1):4-9. 6. Buchanan TA, Xiang AH. Gestational Diabetes Mellitus. The Journal of Clinical Investigation. 2005 March;115(3):485-91. 7. Dabelea D, Snell-Bergeon JK, Hartsfield CL, Bischoff KJ, Hamman RF, Mcduffie RS. Increasing Prevalenceof Gestational Diabetes Mellitus (GDM) Over Time and by Birth Cohort. Diabetes Care. 2005 March;28(3):579-84. 8. Ministry of Health Malaysia. Diabetes Mellitus. The Third National Health and Morbidity Survey, 2006 (NHMS III): Executive Summary. Kuala Lumpur: Institute of Public Health (IPH), Malaysia; 2008, p. 55-7. 9. Ministry of Health Malaysia. Diabetes Admission and Death by Type of Diabetes for Malaysia. Putrajaya: Ministry of Health Malaysia; 2007, p. 18. 10. Chan S. Prevalence of GDM in Malaysia. ASGODIP Report: ASEAN, 7th Congress of ASEAN Federation of Endocrine Society, 1993. 11. Shamsuddin K, Mahdy ZA, Rafiaah SI, Jamil MA. Risk Factor screening for abnormal glucose tolerance in pregnancy. International Journal of Gynecology and Obstetric 2001;75:27-32. 12. Maternal And Child Health Unit. Towards Improving the Management of Gestational Diabetes in Kulim District. District Specific Approach; Kulim District Health Office, 2003.
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References
13. Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational Diabetes Mellitus: Prevalence, risk factors, maternal and infant outcomes. International Journal of Gynecology and Obstetric. 2001;75:221-8. 14. Stone CA, McLachlan K, Halliday JL, Wein P, Tippett C. Gestational Diabetes in Victoria in 1996: incidence, risk factors and outcome. MJA. 2002 November;177:484-91. 15. Keshavarz M, Cheung NW, Babaee GR, Moghadam HK, Ajami ME, Shariati M. Gestational Diabetes in Iran: Incidence, risk factors and pregnancy outcomes Diabetes Research and Clinical Practice. 2005 January;69:279-86. 16. Savona-Ventura C, Azzopardi J, Sant R. Risk Factors for Gestational Diabetes Mellitus in the Maltese Population: a population based study. International Journal of Risk and Safety in Medicine. 2000;13:1-7. 17. Murgia C, Berria R, Minerba L, Sulis S, Murenu M, Portoghese E, et al. Risk assessment does not explain high prevalence of gestational diabetes mellitus in a large group of Sardinian women. Reproductive Biology and Endocrinology. 2008; 6:26. 18. Kieffer EC, Carman WJ, Gillespie BW, Nolan GH, Worley SE, Guzman JR. Obesity and Gestational Diabetes Among African-American Women and Latinas in Detroit: Implication for Disparities in Women's Health. JAMWA. 2001;56:181-7. 19. Cianni GD, Volpe L, Lencioni C, Miccoli R, Cuccuru I, A.Ghio, et al. Prevalence and risk factors for gestational diabetes assessed by universal screening. Diabetis Research and Clinical Practice. 2003;62:131-7. 20. Bryson CL, Ioannou GN, Rulyak SJ, Critchlow C. Association between Gestational Diabetes and Pregnancy-induced Hypertension. American Journal of Epidemiology. 2003; 158:1148-1153.

21. Idris N, Che Hatikah CH, Murizah MZ, Rushdan MN. Universal versus selective screening for detection of gestational diabetes mellitus in a Malaysian population. Malaysian Family Physician. 2009;4(2&3):83-87
22. Setji TL, Brown AJ, Feinglos MN. Gestational Diabetes Mellitus.Clinical Diabetes. 2005; 23:17-24 23. Metzger BE, Buchanan TA, Coustan DR, Leiva AD, Hadden DR, Hod M, et al. Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007 July; 30, Supplement 2:251-60
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