Pregnancy Outcome Among Women with Diabetes Mellitus in Pregnancy at a Tertiary Health Centre in North-Western Nigeria

: Background: Diabetes mellitus (DM) has a significant public health problem globally and the International Diabetes Federation (IDF), has estimated that the number of cases of diabetes mellitus would likely increase to 700 million by the year 2045. It is a common endocrine disorder in pregnancy and complicates upto 10% of pregnancies. Objective: The aim of this study is to review the pregnancy outcome among women with Diabetes Mellitus in pregnancy at Usmanu Danfodiyo University Teaching Hospital (UDUTH) and to compare the outcomes between pregestational Diabetes mellitus and Gestational diabetes mellitus. Methodology: This was a retrospective study of cases of Diabetes mellitus managed at UDUTH over five years (January, 2017 to December 2021). The list of case notes managed was obtained from Health records department of the institution and the case notes were retrieved. Relevant information was obtained and entered in Statistical package for social sciences version 25. Chi Square test was used to compare pregnancy outcome between pregestetional Diabetes mellitus and Gestational Diabetes mellitus. Level of significance was set at p<0.05. Result: The mean age of the cases was 31.8 ± 5.2, the youngest was 21 years and the eldest was 43 years. The median parity was 3 and highest parity was para 8. For those that carried the pregnancy beyond age of viability, the mean gestational age at delivery was 38 ± 2.2 weeks and the mean birth weight was 3.7 ± 0.8kg. The least birth weight was 1.3kg and the highest birth weight was 6kg. Among the cases, 51.3% had no coexisting hypertensive disorder in pregnancy. The major mode of delivery was by caesarean section (57.8%) and majority (92%) had live babies.The major indication for caesarean section was fetal macrosomia. There was no significant association between the type of Diabetes in pregnancy and pregnancy outcome. Conclusion: Majority of the cases had caesarean section and live babies. The pregnancy outcome between pregestational Diabetes mellitus and Gestational diabetes mellitus were similar. Most of the neonates had no congenital abnormality and majority were not admitted in intensive care baby unit. However, the main fetal complication was fetal macrosomia.


Introduction
Diabetes Mellitus is a common endocrine disorder in pregnancy and complicates up to 10% of pregnancies overall, and up to 40% of pregnancies in communities with racial predilection for the disease (John, Alegbeleye, & Otoide, 2015;Fraser, & Farell, 2011). The International diabetes Federation (IDF), has estimated that the number of cases of diabetes would likely increase to 700 million by the year 2045. The rise in incidence in recent years is probably due to increasing obesity and advanced maternal age. Pregestational diabetes (PGDM) is the term used to refer to type 1 and type 2 diabetes occurring before pregnancy while gestational diabetes (GDM) is the one that presents for the first time in pregnancy (John, Alegbeleye, & Otoide, 2015;Fraser, & Farell, 2011;Wokoma, John, & Enyindah, 2001;Buchanan, & Xiang, 2005). Diabetes Mellitus in pregnancy could be associated with an increased risk of recurrent miscarriages, congenital abnormalities, intrauterine death, fetal macrosomia, early onset of hypertensive diseases in pregnancy, difficult deliveries and increased operative delivery as well as birth injuries (John, Alegbeleye, & Otoide, 2015;Lucas, 2001;John et al., 2020).
In the neonatal period, there is also rise of birth asphyxia, hypoglycemia and respiratory distress syndrome to the infants of mothers with diabetes mellitus. From the second trimester of pregnancy, the maternal and perinatal risk of adverse outcomes for both pre-gestational and gestational diabetes are similar. However, because of hyperglycemia in the pre-conception and early conceptions period, infants of mothers with PGDM experience double risk of birth injury, triple the likelihood of caesarean delivery and four times the incidence of new born intensive care admissions (John, Alegbeleye, & Otoide, 2015;Bener, Saleh, & Al-Hamaq, 2011;Ugboma, Aburoma, & Ukaigwe, 2012;Ozumba, Obi, & Oli, 2004).

Early
identification and appropriate management of diabetes mellitus complicating pregnancies have been found to reduce the associated infants morbidity and mortality . 9,10 Therefore, the management of PGDM should begin in the preconception period as proper glycaemic control is essential for better outcomes.
The objective of this study was to determine the pregnancy outcome among women with diabetes in pregnancy at Usmanu Danfodiyo University Teaching Hospital (UDUTH) and to compare the outcome between pregestational diabetes mellitus and gestational diabetes mellitus.

Methodology
This was a retrospective study of cases of Diabetes mellitus managed at UDUTH over five years (January, 2017 to December 2021). The list of cases notes managed was obtained from Health records department of the institution and the case notes were retrieved. Relevant information was obtained and entered in Statistical package for social sciences version 25. Tables and figures were used to display results. Chi square test was used to test the association between the two groups as appropriate. The level of significance was set at P < 0.05 at 95% confidence interval.
Ethical approval was sought and obtained from the health research and ethics committee of UDUTH, Sokoto.

Results
The mean age of the cases was 31.8 ± 5.2 years, the youngest was 21 years and the eldest was 43 years. The median parity was 3 and highest parity was para 8. For those that carried the pregnancy beyond age of viability, the mean gestational age at delivery was 38 ± 2.2 weeks and the mean birth weight was 3.7 ± 0.8kg. The least birth weight was 1.3kg and the highest birth weight was 6kg.
Most of the cases with pre-gestational diabetes mellitus were 35years and above. There was statistical significant association between maternal age and type of DM (χ 2 = 8.2, p-value = 0.04). However, there was no statistically significant association between the ethnicity, religion, educational status, booking status, parity and the type of DM. This is shown in Table 1. Majority of the cases with both pre-gestational diabetes and gestational DM had Caesarean section; However, there was no significant association between the mode of delivery and type of Diabetes mellitus (χ 2 = 7.597, P value = 0.070). The most common indication in both was fetal macrosomia. Among those that had spontaneous vaginal delivery (SVD), majority had no complication. The major SVD complication in both was fetal macrosomia. This is shown in Table 2. Majority of the cases with both pre-gestational diabetes mellitus and gestational Diabetes mellitus had first and fifth minute Apgar score of 7 and above and there was no significant association between the two groups. This is shown in the Table 3. Most of the neonates had no congenital abnormality and majority were not admitted in neonatal intensive care.
Fifty percent of the neonates of those with GDM had fetal macrosomia compared to 36.8% of those with preexisting DM. However, there was no statistically significant association between the type of DM and birth weight (χ 2 =1.668, P value 0.197). This is shown in Table 3.

Discussion
In this study we evaluated feto-maternal outcomes in all pregnancies complicated by diabetes mellitus (DM) from 2017 to 2021 at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Northwest Nigeria. The majority of our patients were between the ages of 21 and 35 years. This finding is similar to other studies from Portharcourt and Lagos Nigeria (John, Alegbeleye, & Otoide, 2015;Ugboma, Aburoma, & Ukaigwe, 2012;Olarinoye, Ohwovoriole, & Ajayi, 2004). These ages represent the most reproductive age group and therefore accounting for the above findings.
Most of the cases with pregestational diabetes mellitus were 35 years and above and there was statistical significant association between maternal age and type of diabetes mellitus (X 2 = 8.2, P -value = 0.04). However, there was no statistically significant association between the ethnicity, religion, educational status, booking status, parity and type of diabetes mellitus.
In this index study, majority of the cases with both pregestational and gestational DM had caesarean section (C/S) However there was no significant association between the mode of delivery and type of DM (X 2 = 7.597, P value = 0.070). This mode of delivery (C/S) is in keeping with the findings of increased rate of caesarean section in all pregnancies complicated by diabetes mellitus in other studies (Ifunanya et al., 2019;Macaulay et al., 2018;Stogianni et al., 2019). The most common indication for CS in both cases was Fetal macrosomia. This was similar to what was found in other studies (John, Alegbeleye, & Otoide, 2015;Buchanan, & Xiang, 2005). Late booking and consequential late identification of both the pregestational and gestational DM among these patients might have accounted for the greater percentage of fetal macrosomia among the cases.
Majority of those that had spontaneous vaginal delivery had no complication. The main complication in both cases was fetal macrosomia. This complication of fetal macrosomia found in both the cases is as a result of poor glycemic control following lack of preconceptional care, late booking and subsequent late identification as well as institution of management. The level of glycemic control is considered to be the most important risk factor for congenital malformation, stillbirth, fetal macrosomia and early neonatal death (Buchanan, & Xiang, 2005).
Therefore, clinical recognition of DM in pregnancy and optimal management including nutritional and insulin therapy are necessary as well as antepartum fetal surveillance in order to reduce the maternal and perinatal morbidity and mortality associated with the condition (Buchanan, & Xiang, 2005;Balsells et al., 2009).

Conclusion
Majority of the cases had caesarean section and live babies. The pregnancy outcome between pregestational Diabetes mellitus and Gestational diabetes mellitus were similar. Most of the neonates had no congenital abnormality and majority were not admitted in intensive care baby unit. However, the main fetal complication was fetal macrosomia.