Transient Hyperglycemia and Gestational Diabetes Mellitus in Preterm Pregnant Women after Receiving Antenatal Steroids

Saniya Naheed1, Sajida Asghar2, Dureshahwar3, Seema Gul4, Mahwash Jamil5, Ayesha Akram6,

1, 2 Assistant Professor, Department of Obstetrics and Gynecology, HBS Medical & Dental College/General Hospital Islamabad
3, 4Assistant Professor, Department of Obstetrics and Gynecology, Watim Medical & Dental College/General Hospital Rawalpindi
5, 66Assistant Professor, Department of Obstetrics and gynecology, HITECH-Institute of Medical Sciences, Rawalpindi.

Background: Preterm births account for increased mortality and morbidity in both developed and developing countries. The objective of this study was to determine frequency of transient hyperglycemia and gestational diabetes mellitus in preterm pregnant women receiving antenatal steroids.
Methodology: This descriptive cross-sectional study was carried out in Maternal and Child Health Center Unit 1 at Pakistan Institute of Medical Sciences, Islamabad from January 2018 till August 2018. 370 pregnant women presenting to hospital who received dexamethasone therapy due to preterm labor, preterm premature rupture of membranes or any other conditions which require early delivery e.g., oligohydramnios etc. were included. Multiple pregnancies, advanced preterm labor, gestational or chronic diabetes mellitus, and those having BSR > 126 mg/dl before first dose of dexamethasone were excluded. After ethical approval and informed consent, proformas were filled. Blood sugar levels before 1st dose of dexamethasone noted and 2nd dose was given after 12 hours. Blood sugar profile (fasting, 2 hours after lunch, 2 hours after dinner) was carried out till euglycemia or 5 days if sugars remain deranged. Patients having deranged levels for greater than 5 days were advised 75 g oral glucose tolerance test and were labeled as having gestational diabetes mellitus.
Some countries such as Ethiopia and Brazil have better life expectancy when seen with respect to their Gross National Income as they have struggled for better health care coverage. On the other hand, a developed country such as USA does not have a life expectancy worth of its GNI which can be due to its market-based health care and less political commitment. Standards of population health is directly related to broad based policies, investment in PHC and universal health coverage in order to achieve positive and equitable population health outcomes - in all countries regardless of their wealth2
Results: Mean age of study participants was 28.92+5.54 years with mean gestational age of 31.19+1.92 weeks. Assessment of transient hyperglycemia and gestational diabetes mellitus in preterm pregnant women receiving antenatal steroids revealed 73.78%(n=273) had transient hyperglycemia, 6.21%(n=23) had gestational diabetes and 26.22%(n=97) had no blood glucose abnormality.
Conclusion: Frequency of transient hyperglycemia and gestational diabetes mellitus increased in pregnant women receiving antenatal steroids. Basic sugar profile should be carried out after dexamethasone therapy.
Keywords: Corticosteroid, Gestational diabetes mellitus (GDM), Hyperglycemia, Preterm

The incidence of preterm birth in developed countries is 12.7% and its rate varies with socioeconomic status.1 Preterm births account for 85% of neonatal mortality and increased morbidity in both developed and developing countries.2 For better feto-maternal outcome, it is important to identify preventable and treatable causes of preterm births3.
Respiratory Distress Syndrome (RDS), a consequence of preterm delivery, due to immaturlung development, is the major reason of early neonatal mortality and morbidity. The RDS has dramatically reduced because of antenatal steroids and exogenous surfactant replacement. In the developing countries, with the scarce resources, especially NICU care, antenatal steroids play a very significant role. They have reduced, risk of RDS from 25.8% to 9.0 % and neonatal mortality has decreased from 15.0% to 3.2%4.
To increase lung maturity, intramuscular injection of Betamethasone or Dexamethasone is given. These are the steroids of choice to improve fetal lung maturity.5 Glucose intolerance, chorioamnionitis, puerperal sepsis, bruising, hematoma, pain at the site of injection, insomnia, gastrointestinal upset, pre-eclampsia is known side effects of steroids6.
A strict control on sugar is very important to reduce the risk of RDS because fetal hyperinsulinemia is key factor in pathogenesis of RDS, administration of antenatal steroids is even more recommended in diabetic women and strict insulin therapy is advised to allow beneficial effects of steroids7.
As people of South Asian descent are more prone to diabetes, Antenatal steroids can cause disturbance in glucose metabolic homeostasis which may have significant maternal and possibly fetal effects. This study is aimed at exploring effects of antenatal steroids on maternal glucose metabolism by finding the frequency of transient hyperglycemia and gestational diabetes mellitus after dexamethasone therapy.

This descriptive cross-sectional study was carried out in Maternal and Child Health Center unit (MCH-1) at Pakistan Institute of Medical Sciences, Islamabad from January 2018 till August 2018, using consecutive nonprobability sampling technique. A total of 370 pregnant women presenting to emergency and outpatient department who received dexamethasone therapy due to either preterm labor (alive morphologically normal babies), preterm premature rupture of membranes (PPROM) or any other conditions which require early delivery (e.g., preeclampsia, intra uterine growth retardation (IUGR), severe oligohydramnios, antepartum hemorrhage (APH) were included. Women having multiple pregnancies, advanced preterm labor (cervix > 5cm dilated), gestational diabetes mellitus (GDM) or type I/II diabetes mellitus (DM), BSR > 126 mg/dl before first dose of dexamethasone, chorioamnionitis and those taking any medication that affects glucose metabolism were excluded from the study. After ethical approval, informed consent was taken from study participants and proformas were filled. Blood sugar levels before the commencement of 1st dose of dexamethasone were noted and 2nd dose of dexamethasone was given after 12 hours of 1st dose. Blood sugar profile (fasting, 2 hours after lunch, 2 hours after dinner) were carried out till euglycemia (BSF < 100 mg/dl, 2 hours post meal 140mg/dl) or 5 days if sugars remain deranged. Patients were labelled as having transient hyperglycemia if their sugar profile got deranged due to dexamethasone therapy but returned to normal within 5 days. Patients having deranged levels for greater than 5 days were advised 75 g oral glucose tolerance test (OGTT) and were labelled as having gestational diabetes mellitus following the NICE criteria for diabetes in pregnancy (BSF > 100 mg/dl and 2 hours PP > 140 mg/dl). SPSS version 26 was used for data analysis, qualitative variables like: transient hyperglycemia, gestational diabetes mellitus (GDM), sugar profile derangement for greater than 5 days were calculated as frequency & percentages. Quantitative variables like age, gestational age, parity was expressed as mean ± SD.

In our study, mean age of the patients was 28.92+5.54 years (Table-1) and mean gestational age 31.19+1.92 weeks. Parity distribution showed that 73.78% (n=273) were between 1-3 paras and 26.22% (n=97) were between 4-5 paras, mean ± SD was calculated as 2.77 ± 1.24 paras. Assessment of transient hyperglycemia and gestational diabetes mellitus (GDM) in preterm pregnant women receiving antenatal steroids revealed 73.78%(n=273) had transient hyperglycemia, 6.21%(n=23) had gestational diabetes and 26.22%(n=97) had no blood glucose abnormality (Table-2 & 3)

Table 1: Age Distribution (n=370)

Age (in years)

No. of patients

%

18-30

213

57.57

31-40

157

42.43

Total

370

100

Mean ± SD

28.92 ± 5.54


Table 2: BSR Derangement. (n=370)

Blood sugar random derangement

No. of patients

%

Yes

273

73.78

No

97

26.22

Total

370

100


Table 3:Frequency of transient hyperglycemia, impaired glucose tolerance and gestational diabetes mellitus (GDM) in preterm pregnant women receiving antenatal steroids. (n=370)

Qualitative variable

No. of patients

%

Blood Sugar derangement

273

73.78

Transient Hyperglycemia

250

67.56

Gestational Diabetes Mellitus

23

6.21

No serum glucose abnormality

97

26.22

Total

370

100

South Asian descents are more prone to diabetes8 and our population has high prevalence of undiagnosed DM and impaired glucose tolerance. Antenatal steroids can cause disturbance in glucose metabolic homeostasis which may have significant maternal and possibly fetal effects. Locally, no or single blood sugar level done, routinely before dexamethasone therapy may be insufficient to judge the glucose metabolic status of women, so this study was aimed at exploring effects of antenatal steroids on maternal glucose metabolism.
Assessment of transient hyperglycemia and gestational diabetes mellitus (GDM) in preterm pregnant women receiving antenatal steroids revealed 73.78%(n=273) had transient hyperglycemia, 6.21%(n=23) had gestational diabetes and 26.22%(n=97) had no blood glucose abnormality. GDM is becoming global health burden with global prevalence of 16.9%. The highest prevalence was seen in South-Asia region of 25% as compared to 10.4% in the North America and Caribbean Region9.
It is established in literature that maternal corticosteroids given for fetal lung maturity increase blood glucose level of the mother.10,11 From previous studies, we have identified that the effects of corticosteroids on blood glucose levels in non-diabetic mothers remain for 24 hours. However, changes in oral glucose tolerance test were noticed for three days after giving betamethasone injections. Ghazala et al12 also found that the steroids have systemic metabolic side effects.
The effects of single and multiple courses of dexamethasone and its effect on maternal fasting and postprandial glucose level were observed in another study. It was found that single course of dexamethasone resulted in acute increase in blood glucose level while multiple courses resulted in continuous increase in blood glucose levels13.
In Our study 73.78% of study participants had deranged blood sugar level after dexamethasone therapy out of which 6.21 % developed GDM whereas 67.51% had transient hyperglycemia, similarly a study by Refuerzo et al showed 16% to 33% increase in glucose level at 20,44 and 68 hours after first dose of antenatal corticosteroids in pregnant women without diabetes which may be missed with conventional monitoring.14 Glucose intolerance is signficantlty higher in twins and triplets compared to singleton15.

Frequency of transient hyperglycemia and gestational diabetes mellitus increased in preterm pregnant women receiving antenatal steroids. Basic sugar profile should be carried out after dexamethasone therapy.

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