This document summarizes a study on the epidemiology of gestational diabetes mellitus (GDM) in Zagazig, Egypt. The study found a 10% prevalence of GDM among 180 pregnant women screened. It identified several risk factors for GDM, including a family history of diabetes (89% of GDM cases), a history of twins (67%), a BMI over 30 (66%), a history of previous GDM or macrosomic baby (61% each), and a history of polycystic ovary syndrome (61%). The document discusses these findings in relation to previous studies on risk factors for GDM.

1. Epidemiology of
Gestational Diabetes
Mellitus(GDM) in Zagazig
BY
MOHAMMAD G. KHALIFA (MSC.)
ASSIST. LECTURER OF INTERNAL MEDICINE ,
DIABETES AND ENDOCRINOLOGY
FACULTY OF MEDICINE , ZAGAZIG UNIVERSITY.
(28TH APRIL, 2017)

2. Introduction…

3. For many years, Gestational diabetes
mellitus (GDM) was defined as any degree of
glucose intolerance that was first recognized
during pregnancy.
ADA definition: GDM is diabetes that is first
diagnosed in the second or third trimester of
pregnancy that is not clearly either
preexisting type 1 or type 2 diabetes (ADA,2017).

4. It is usually recognized at 24 to 28 weeks of
gestation on the basis of abnormal glucose
tolerance testing. Additionally, pregnancy can be
complicated by established type 1 or type 2
diabetes. (ADA,2015).
In the 2011 Standards of Care, the ADA for the
first time recommended that all pregnant women
not known to have prior diabetes undergo a 75-g
OGTT at 24–28 weeks of gestation, based on a
recommendation of the IADPSG(ADA,2017)

5. There are limited data regarding the
prevalence of GDM worldwide.
One report by the National Institute for
Health and Care Excellence (NICE) in the
UK suggests that the prevalence of GDM
in England and Wales is approximately
3.5% of all pregnancies.(National Collaborating
Centre for Women's and Children's Health, 2015).

6. The prevalence of GDM varies from 1-
20%, and is rising worldwide, parallel
to the increment in the prevalence of
obesity and type 2 diabetes mellitus
(T2DM). (WHO, 2013).

7. During normal pregnancy, resistance to insulin
action increases. In most pregnancies,
pancreatic beta cells are able to compensate for
increased insulin demands,and normoglycaemia
is maintained.
In contrast, women who develop GDM have
deficits in beta-cell response leading to
insufficient insulin secretion to compensate for
the increased insulin demands (ADA, 2015).

8. Products of the placenta, including tumor
necrosis factor-alpha (TNF-alpha) and human
placental lactogen, are thought to play key roles in
inducing maternal insulin resistance.
Insulin resistance is most marked in the third
trimester , the reason that screening has
traditionally been performed at this point
(Metzger et al., 2007).

9. It is well known that the women who are at the
greatest risk of developing GDM are those who
have a history of glucose intolerance or past
gestational diabetes, have delivered a child with
macrosomia or a child who was large for
gestational age, suffer from polycystic ovary
syndrome or have first degree relatives with
diabetes. The prevalence of GDM increases with
age from 25 years old (NICE, 2015).

10. GDM is associated with maternal and
neonatal adverse outcomes such as :
Gestational hypertension, polyhydramnios, need for cesarean
delivery, maternal trauma from operative delivery ,preterm
labor, fetal macrosomia , shoulder dystocia , preterm delivery
,fetal cardiomyopathy ,Stillbirth, Congenital malformations,
Respiratory distress syndrome and lung immaturity,, Small-
for-gestational-age (SGA), increased risk of developing
diabetes mellitus and obesity ,and hyperbilirubinemia.

23. Aim and objectives
of the work…

24. The aim of the work was early diagnosis,
prevention and detection of prevalence of
GDM by universal screening in all non-
diabetic women attending to outpatient
clinics of Zagazig University Hospitals,( in
light of new diagnostic criteria of the
International Association of Diabetes and
Pregnancy Study Groups) (IADPSG).

25. The main objectives of our study
were to :
determine the prevalence of GDM
and predict the potential risk factors
among the study group.

26. SUBJECTS
AND
METHODS…

27.  This study was carried out in outpatient clinic of
Internal Medicine Department, and Obstetrics
and gynecology Department in Zagazig University
Hospitals , in the period from December 2014 to
December 2015.
It was a cross sectional study including a total
number of 180 volunteer pregnant subjects.

28. Inclusion criteria…
Co-operative subjects.
Pregnant females
Gestational age: 24 – 28 weeks.
Non diabetic.

29. Exclusion criteria…
Pregnant women who were known diabetic.
Drug intake that can cause hyperglycemia
such as corticosteroids.

30. Methods:
All subjects of the study were subjected to:
A. Full history taking including: Age, previous
history of GDM, family history of diabetes in first
degree relatives, previous macrosomic baby,
polycystic ovary syndrome, Twin pregnancy ,and
Drug history.
B. Clinical examination: Full clinical examination.
C. Investigations :

31. 1-oral glucose tolerance test “OGTT”
75-g OGTT will done, with plasma glucose
measurement when patient is fasting and
at 1st and 2nd hour , at 24–28 weeks of
gestation in women not previously
diagnosed with overt diabetes.

32. The diagnosis of GDM is made when any of
the following plasma glucose values are
met or exceeded:
Fasting: 92 mg/dL (5.1 mmol/L).
1st hour: 180 mg/dL (10.0 mmol/L).
2nd hour : 153 mg/dL (8.5 mmol/L).

33. 2-HbA1c:
HbA1c was done to distinguish
GDM from pre-existing diabetes.
Patients with Hb A1c levels of 6.5% or
higher were considered to have overt
diabetes.

34. Results
…

35. Prevalence of GDM
Variable
Cases(n=180)
No %
GDM
No
Yes
162
18
90
10
90%
10%
Normal cases Cases with GDM

36. Variable
Cases
(n=18)
HbA1c (%)
Mean ± SD
Range
5.23 ± 0.42
4.5 – 6
HbA1c of the GDM group

37. Comparison between cases with GDM
and normal cases in Demographic data
Variable
No GDM
(n=162)
GDM
(n=18)
t P
Age (year)
Mean ± SD
Range
25.48 ± 2.95
19 – 32
25.44 ± 5.38
20 – 37
0.04
0.97
NS
Age of marriage (year)
Mean ± SD
Range
21.44 ± 1.26
19 – 25
28.5 ± 7.03
19 – 35
11.45 <0.001**

38. Comparison between cases with GDM and
normal cases as regard Body Mass Index (BMI)
and Glycemic Index (GI) of the diet
Variable
No GDM
(n=162)
GDM
(n=18)
t P
BMI (Kg/m2)
Mean ± SD
Range
26.83 ± 1.08
24.1 – 29.8
31.04 ± 2.2
27.7 – 37.7
13.77 <0.001**
Diet
Average GI diet
High GI diet
No % No %
65.55 <0.001**162
5
96.9
3.1
11
7
61.1
38.9

39. Comparison between cases with GDM
and normal cases in gynecological history
Variable`
No GDM
(n=162)
GDM
(n=18)
t / χ2 p
No. of pregnancy
Mean ± SD
Range
1.95 ± 0.83
1 – 4
4.39 ± 1.42
1 – 7
10.84 <0.001**
History of twins
No
Yes
No % No %
115.7 <0.001**162
0
100
0
6
12
33.3
66.7
History of macrosomic baby
No
Yes
162
0
100
0
7
11
38.9
61.1
105.4 <0.001**
History of PCOS
No
Yes
162
0
100
0
7
11
38.9
61.1
105.4 <0.001**
Gestational Age (weeks)
Mean ± SD 26.12 ± 1.87
24 – 28
26.12 ± 1.87
24 – 28
1.62
0.11
NS

40. Comparison between cases with GDM and
normal cases in family history of diabetes and
history of GDM
Variable
No GDM
(n=162)
GDM
(n=18) χ2 P
No % No %
Family history of DM
No
Yes
128
33
79
20.4
2
16
11.1
88.9
38.39
<0.001**
History of previous GDM
No
Yes
162
0
100
0
7
11
38.9
61.1
105.4 <0.001**

41. Family History of DM in cases with GDM
89%
11%
Positive family history of DM
Negative family history of DM

42. History of twins in cases with GDM
66.7 %
33.3 %
Cases with GDM with history of…
Cases with GDM with no history…

43. History of PCOs in cases with
GDM
61%
39%
Cases with GDM with history of
PCOs

44. History of previous GDM in cases with GDM
61.1%
38.9 %
Positive History of previous GDM
Negative history of previous GDM

45. History of macrosomic baby in cases with
GDM
39%
61%
Cases with GDM without history of macrosomic baby
Cases with GDM with history of macrosomic baby

46. 61%
39%
Diet in cases with GDM
Averge GI Diet High GI Diet

47. Net Results
and
conclusion…

48. * The prevalence of GDM among all cases included
is10%.
* The risk factors of GDM respectively are : family
history of DM, history of twins, BMI above 30, history
of previous GDM , history of previous macrosomic
baby and history of PCOS which are equal, history of
grand multipara, maternal age above 35 years old,and
lastly history of diet with high glycemic index.

49. Risk Factors for GDM
89.00%
67% 66.00% 61.10% 61.10% 61% 56% 44% 38.90%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Estimated Risk for GDM %

50. Discussion
…

51. The main objectives of our study
were to determine the prevalence of GDM
and predict the potential risk factors
among the study group.
Using the new IADPSGs criteria, our
study revealed that the prevalence rate of
GDM is 10% among the study cases.

52.  . Theses results were both in conflict and in
agreement with some studies conducted in
the arabic countries as Bahrain, Kuwait,
Oman, Qatar, Saudi Arabia, and the United
Arab Emirates.
In general, the prevalence rate observed in
this study was related to the universal
range varying from 3% to 14% among all
pregnancies in different populations as
declared by Ben-halima et al. 2012.

53. The Prevalence rate of our study is also in
agreement with the that of GDM in different
parts of the world that ranged between 1 %
to 14 % in different areas (lowest was less
than 1% in a study conducted in Singapore
and Tanzania as mentioned by
Ben‐Haroush et al. 2004 and highest was
14% in India as explained by Colussi et al.
2015.

54. Our study rated the following to be the most
important risk factors for GDM respectively:
family history of diabetes ,, history of twins,
body mass index (BMI) above 30 , history of
previous GDM, history of macrosomic baby
above 4.5 kg , history of PCOS, grand parity
( delivery of 5 children or more ), maternal
age above 35 years, and lastly diet with high
glycemic index (GI).

55. Asregard family history of DM , our study
revealed that it is an important risk factor for
occurrence of GDM, as 88.9 % of cases with
GDM had family history of DM.
This is in agreement with what was explained
by Bhat et al. in 2010 who explained that Family
history of diabetes was concluded in several
cross sectional and prospective studies as a
highly significant risk factor for developing
GDM.

56. In 2011 Marcinkevage et al explained that:
family history of diabetes mellitus is widely
recognized as an effective risk factor on the
prevalence of GDM.
Gomez et al in 2011 declared that family history of
DM occurred in 77.7 % of cases included in a
study that was held to determine risk factors of
GDM.

57. As regard history of twins as a risk factor for
occurrence of GDM , our study revealed that
history of twins occurred in about 67 % of cases
with GDM (12 of 18 cases with GDM) and this is of
statistical significance .
Kjos and Buchanan in 1999 declared that many
studies show that 17 to 67 % of cases with GDM
included had previous history of twin pregnancy.

58. Obesity as a significant risk factor for GDM
is supported by several studies finding that
overweight or obesity at the start of
pregnancy predispose to GDM .
Our study found that BMI above 30 kg/ m2
is of statistical significance for occurrence
of GDM as about 66 % of cases with GDM
had BMI above 30kg/m2.

59. Our study results in this point are near to
the results of the recent Atlantic DIP 2014
study that reported that over 50% of women
who were overweight (BMI 25–29.9 kg/m 2)
at the first antenatal visit had excessive
gestational weight gain, and developed
GDM during subsequent pregnancies as
declared by Yessoufou and Moutairou,
2011.

60. As regard history of previous GDM, macrosomic
baby and history of PCOS, Our study declares
that these factors are found to be associated
with occurrence of GDM, as these three risk
factors occurred in 61% of GDM cases equally.
Our study in this point are near to the results
founded by Marcinkevage and Narayan, 2011
who declared that these factors are widely
recognized as the effective risk factors on the
prevalence of GDM.

61. It is also in agreement with what explained
by Ashrafi et al. 2014 who explained that
previous reports around the world found
that the following health variables have
been found to be significant risk factors for
GDM: age ≥ 35 years, BMI ≥ 30 kg/m2,
previous GDM, family history of diabetes,
previous macrosomic baby, and history of
PCOs.

62. Astudy conducted in Yamen in 2016 to detect
prevalence and risk factors for GDM ,revealed
that previous GDM, age ≥ 35 years, family
history of diabetes, and history of PCOS as the
strongest predictors for developing GDM.
Beneret et al. in 2011 said that evidences from
earlier surveys indicated that previous GDM and
age ≥ 35 years are more associated with GDM
than the other risk factors.

63.  Our study show that history of grand
multipara (A woman who has given birth 5 or
more times) is a risk factor for GDM (it
occurred in 55.5 % GDM cases), and this is
consistent with what declared by Roman et
al.in 2007 who assessed the obstetric and
neonatal outcomes in grand multi-parity and
found that grand multi-para had a higher
rate of GDM.

64. A study conducted in Pakistan to assess
the Socio-demographic risk factors of
GDM shew that, the number of GDM
women with grand multi-parity was 54.4%
which was significantly higher than the
healthy pregnant women, as mentioned
by Moses et al. in 2011.

65. Our study in this item revealed that, history of
high GI diet is a risk factor for occurrence of
GDM ( occurred in 38.9% of GDM cases ).
Result of our study in this point is in agreement
with the results of a study held in Lady Hardinge
Medical College in New Delhi to assess the
nutritional risk factors for GDM, which show that
women consuming diet of high GI had high risk
of GDM. (Zhang and Ning, 2011).

66. Zhang et al. in2006 conducted a hospital
based prospective cohort study in USA to
examine whether dietary Glycemic Index
was related to GDM risk or not . This
study show that dietary Glycemic Index
was positively related to GDM risk.

67.  Finally, our study gives information about the
risks of GDM that can help improve primary
health care measures. However, all pregnant
women should be screened for GDM even they
have the risk factors or not .
Scott et al., 2002 declared that recognizing such
risk factors among pregnant women is important
and should be done by the medical staff in order
to prevent the adverse effects of GDM.

68. Recommendations…

69. we recommended the following:
All pregnant women should be screened
for GDM at 24 –28 weeks of gestation.
On presence of GDM risk factors,
screening should be done at any stage in
the pregnancy .If the initial screening is
performed before 24 weeks of gestation
and is negative, rescreen between 24 and
28 weeks of gestation.

70. A 75 g OGTT can be performed (with no prior
screening 50 g GCT) as the diagnostic test for
GDM using the IADPSG criteria .
Further studies are needed to focus on
detection of prevalence, early diagnosis,
management of GDM and its risk factors.
Follow up of mothers and their offsprings to
prevent occurrence of diabetes mellitus in
both.

71. THANK YOU