CONGENITAL ANOMALIES AND PERINATAL MORBIDITIES IN INFANTS BORN TO

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					      CONGENITAL ANOMALIES AND PERINATAL
   MORBIDITIES AMONG INFANTS BORN TO DIABETIC
     MOTHERS-A RETROSPECTIVE COHORT STUDY




                     DEPARTMENT OF COMMUNITY MEDICINE,
                    MEDICAL COLLEGE, THIRUVANANTHAPURAM




Guided by                                   Submitted by

       Dr. Reshmi Ramachandran                        Rebecca George
                                                      Reshma.M
                                                      Reshmi Raveendran
                                                      2006 MBBS



                                                                          1
                                       CERTIFICATE


                          DEPARTMENT OF COMMUNITY MEDICINE,
                         MEDICAL COLLEGE, THIRUVANANTHAPURAM




Report of a project work done on 2009-2010 on congenital anomalies and perinatal morbidities in infants
born to diabetic mothers-retrospective cohort study



Guided by                                                             Submitted by
Dr. Reshmi                                                           Rebecca George
                                                                     Reshma.M
                                                                     Reshmi Raveendran

Certified that this report is a bonafide record of research project undertaken to fulfill the curriculum
requirements of the graduate medical education as stipulated by the Medical Council of India and was
done during the year 2009-2010.




                                                                           Dr. K.Vijayakumar
Date                                                                   Professor and Head of Department



                             Office seal




                                                                                                           2
                             ACKNOWLEDGEMENT




First and foremost we would like to extend our thanks to the Department of Community Medicine, Medical
College, Thiruvananthapuram and the SAT hospital for having given us such a wonderful opportunity to do
this study.

With a deep and special debt of gratitude, we express our grateful acknowledgement to our professor in
Community Medicine Department, Dr.Vijayakumar for having helped us during the course of this project.

We also express our sincere gratitude and thanks to our guide Dr.Reshmi for her continued inspiration and
guidance till the completion of this work.

We are greatly indebted to the Department of Obstetrics and Gynaecology, SAT hospital
Thiruvananthapuram for having helped us in the collection of materials for the project.

We would also like to express our gratitude to the patients who have corporated with us in sharing valuable
information.

Lastly but most important, we offer our special recognition and thanks to Almighty God for having helped
us in bringing out this project to the best of our ability.




                                                                                                         3
                                EXECUTIVE SUMMARY


Introduction: diabetes during pregnancy increases the risk of congenital anomalies and perinatal
morbidities than in general population. Anomalies are found to occur 3 times more among infants born
to diabetic mothers. Objective: to study the proportion and determinants of congenital anomalies and
perinatal morbidities among infants born to diabetic mothers. Methodology: a retrospective cohort
study was done in a study population of 142 postnatal women admitted at SAT hospital who had either
pregestational or gestational diabetes antenataly, during the time period of 2 months from October 2009
to December 2009. Results: 16.9% of the study population had pregestaional type of diabetes, 83.1% of
gestational diabetes.66% of the deliveries were caesarean and out of the infants born 5.6% had
congenital anomalies vise VSD(2.8%), ASD(1.4%), Hydronephrosis(1.4%) . 45.1% of the infants had
growth abnormality either LGA(21.1%) or SGA(23.9%). Hypoglycemia were found in 53.5% ,
respiratory distress in 39.4% and polycythemia in 2.8% and there was one case of stillbirth (.7%). 45.1
% had APGAR at 1 mnt below 8 and 5% had APGAR at 1 mnt below 5. Conclusions: 29.5% of the
babies born were normal and 70.5% of the babies had either anomalies or other morbidities. It was
found that congenital anomalies occur more among women with pre existing diabetes with a relative risk
of 5.583and p value <.001. also an association between congenital anomalies and glycemic control is
found to exist with a relative risk of 2.913 and p value <.001.also it is found that there is a greater risk of
getting hypoglycemia in growth abnormalities with a relative risk of 3.163 and p value <.001. Relations
between prematuriy and respiratory distress is also established with a relative risk of 3.163 and p value
<.001 . Preexisting diabetes and older age among mothers is also related with a risk of 4.917 and p value
<.001. Recommendations: Preconceptional diabetic control should be more emphasized and there
should be strict monitoring of sugar levels and elderly women should be careful before and after
conception since they have got a greater chance of having pre existing diabetes.




                                                                                                                  4
                         CONTENTS

EXECUTIVE SUMMARY                   4

INTRODUCTION                        6

OBJECTIVE                           7

METHODOLOGY                          8

RESULTS AND DISCUSSION              10

CONCLUSIONS                         25

RECOMMENDATIONS                     26

BIBLIOGRAPHY                        27

APPENDIX                            28




                                         5
                                          INTRODUCTION


    Diabetes has long been associated with maternal and perinatal morbidity and mortality. Before the discovery
    of insulin in 1921, women with diabetes rarely reached reproductive age or survived pregnancy. In fact,
    pregnancy termination was routinely recommended for women with diabetes because of high mortality rates.

    Fetal and neonatal mortality rates were as high as 65% before the development of specialized maternal, fetal,
    and neonatal care. Since then, infants of diabetic mothers (IDMs) have experienced a nearly 30-fold decrease
    in morbidity and mortality rates.. According to a study, Infant of diabetic mother , published in emedicine.
    medscape.com, today, 3-10% of pregnancies are affected by abnormal glucose regulation and control. Of
    these cases, 80-88% are related to abnormal glucose control of pregnancy or gestational diabetes mellitus. Of
    mothers with preexisting diabetes, 35% had type 1 diabetes mellitus, and 65% had type 2 diabetes mellitus.

    Infants born to mothers with glucose intolerance are at an increased risk of morbidity and mortality related to
    the following:

       Respiratory distress
       Growth abnormalities (large for gestational age [LGA], small for gestational age [SGA])
       Hyperviscosity secondary to polycythemia
       Hypoglycemia
       Congenital malformations
       Hypocalcaemia, hypomagnesaemia, and iron abnormalities

    According to previous studies as published in bioline.org, major congenital malformations are found in 5-9%
    of affected infants prematurity in 14-36%, macrosomia in 20-30%,hypoglycemia in 15-50%, Polycythemia
    in 10-20%, SGA in 2 %, RDS in 2 – 34% and mortality rates are 5.3%. 62% of babies were delivered by
    caesarean section

    The 1988 National Maternal and Infant Health Survey conducted in USA reported that diabetes complicated
    4% of pregnancies resulting in live births. Of these, 88% were the result of gestational diabetes mellitus, 8%
    were the result of non–insulin-dependent diabetes, and 4% were from insulin-dependent diabetes mellitus.
    Given estimates of 0.2-0.3% of pregnancies complicated by preexisting diabetes and a further 1-5%
    complicated by gestational diabetes mellitus, approximately 50,000-150,000 infants are born to diabetic
    mothers every year.
    Although rates of adverse outcome have decreased dramatically over the past four decades, the prevalence of
    congenital anomalies among infants born to diabetic mothers still remains well above that for infants of
    nondiabetic women. Currently, rates of perinatal morbidity and mortality, resulting mainly from poor
    glycemic control both before conception and during gestation, are approximately three to five times higher
    than for infants of nondiabetic women. And it is in this context we are conducting this study to evaluate these
    problems in our population by trying to find out the proportion of various morbidities and congenital
    anomalies and their various determinants among infants born to diabetic mothers.




                                                                                                                 6
                               OBJETIVE



To find the proportion and determinants of congenital anomalies and perinatal
              morbidities among infants born to diabetic mothers




                                                                                7
                              METHODOLOGY

 STUDY DESIGN: Retrospective cohort study

 STUDY SETTING: SAT Hospital, Thiruvananthapuram


 STUDY SUBJECTS: 142 post natal women admitted in the wards of SAT Hospital who
 had history of diabetes antenataly, either preexisting or gestational
 INCLUSION CRITERIA: .Cases include postnatal women admitted in SAT, Who had either
 abnormal GCT more than 230 or GCT value more than 130 and 2 abnormal GTT values,
 antenataly.


 STUDY PERIOD: Two months from October 2009 to December 2009


 DATA COLLECTION: Data is collected by a semi structured questionnaire.

 ETHICAL CONSIDERATION:
 Ethical clearance was obtained from Department of Community medicine and Department
 of obstetrics and gynecology. Informed consents were taken from all study subjects

 LIMITATIONS:

1.All anomalies would not have been detected at the time of data collection.
2.Pre existing diabetes diagnosed during pregnancy are considered as gestational diabetes

 VARIABLES

 Demographic variables:
 Age, Occupation (unskilled, skilled), Socio economic status, (Below Poverty Line, Above
 Poverty Line), weight, height, BMI( weight / square of height in meters),
 Obese or overweight (those with BMI more than 25)

 Obstetric variables:
 Parity (no of times a woman has bore a viable foetus), type of delivery (caesarean, normal
 delivery) condition of previous baby(normal, LGA, RDS, anomalies, abortion, stillbirth)

                                                                                            8
Maternal variables:
History of Gestational Diabetes Mellitus,
type of diabetes( pre gestational or overt diabetes- diabetes which existed prior to
pregnancy either type 1 or type 2. Type 1 –insulin dependant diabetes, type 2 non insulin
dependant diabetes)
( gestational diabetes –carbohydrate intolerance of variable severity , with onset or first
recognition during present pregnancy)
Family history of DM, history of other diseases, insulin intake,
Glycemic Control( fasting plasma sugar less than 95 mg/ dl and 2 hour post prandial value
less than 120 mg/dl)

Infantile variables:
Weight of present baby, APGAR score, Gestational age( Prematurity- when born before 37
weeks of gestation)

Morbidity variables:
 growth abnormality ( Large for Gestational Age- infants weighing more than 3.5 kg, Small
for Gestational Age- infants weighing less than 2.5 kg)
Respiratory distress, Hypoglycemia ( neonatal plasma sugar level less than 40 mg/ dl),
Polycythemia( hematocrit value more than 65%)

CVS anomalies( cardiomyopathy, outflow tract obstruction, Ventricular Septal Defect,
Atrial Septal Defect, Transposition of great arteries, coartation of aorta)

CNS anomalies(caudal agenesis, anencephaly, spina bifida, immature suckling pattern)

GIT anomalies( duodenal or colorectal atresia, Small left colon Syndrome

Genitourinary( ambiguous genitalia)




                                                                                          9
                                RESULTS AND DISCUSSION
A study was conducted among 142 diabetic mothers, both gestational and pre existing, admitted in the SAT
hospital, medical college Trivandrum during the period of 2 months, to find the proportion and
determinants of congenital anomalies and other perinatal morbidities among infants born. And the
following results were obtained


 Proportion of different characteristics among study population


TABLE 1

                        Age     Frequency      Percent

                        >35     20             14.1

                        <35     122            85.9

                        Total   142            100.0



85.9% of the study population had age below 35 years. Younger age group predominates study population.
The average age of the diabetic mothers studied

TABLE 2
      ses          Frequency         Percent

          BPL      92                64.8

          APL      50                35.2

          Total    142               100.0



64.8% of the study population is below poverty line. This could be justified by the fact that the study is
conducted in tertiary care centre and the majority coming would be poor people.

TABLE 3


                                       Frequency         Percent

          Obese or overweight          82                57.7

          normal                       60                42.3

          Total                        142               100.0

57.7% of the study population were obese or overweight that is BMI greater 25.this could be justified by
the fact that obesity is a risk factor for gestational diabetes as established by a study in St. Mary medical
school, London.
                                                                                                                10
TABLE 4


      Family history
      of diabetes                     Frequency       Percent

                          yes                  40            28.2

                          no                  102            71.8

                          Total               142           100.0


     only 28.2% of the mothers had family history of diabetes. Though it is a risk factor for gestational
diabetes, there are other Independent risk factors like obesity and age greater than 25 as found in an earlier
study conducted in south India.



TABLE 5


     History of
     GDM                         Frequency    Percent

                  yes                    46          32.4

                  no                     96          67.6

                  Total                 142         100.0

32.4 % of mothers under study had previous history of gestational diabetes




TABLE 6

     Presence of
     other disease                    Frequency      Percent

                       present                 31           21.8

                       absent                 111           78.2

                       Total                  142       100.0

21.8% had history of other diseases during pregnancy. Its significance lies in the fact in an earlier study
conducted it was found that though infants born to diabetic mothers seem to be larger presence of
cardiovascular disease causes decrease in birth weight.

                                                                                                              11
TABLE 7

      Type of
      diabetes       Frequency    Percent

      pre existing           24          16.9

      gestational           118          83.1

      Total                 142         100.0

   83.1% of the study subjects had gestational diabetes and 16.9% had known diabetes. Proportion of pre
   existing diabetes could be still higher since previously undiagnosed diabetes would have got detected only
   during pregnancy. Generally hyperglycemia during first trimester occurs due to pre existing diabetes.
   According to previous studies most of the morbidities have higher rate of occurrence with pre existing
   diabetes.




   TABLE 8

      Type of delivery     Frequency      Percent

      caesarian                    94            66.2

      normal pregnancy             48            33.8

      Total                       142           100.0



   66.2 % of deliveries were by caesarean section. According to a cross sectional study conducted in Madras
   rate of caesarean section occurring in Public health sector is only 20 %. but it is found to be more than 3
   times higher than average rates. This could be due to the fetal distress and macrosomia caused due to
   diabetes and also due to this study being conducted in a tertiary care centre where more complicated
   pregnancies like breech presentations, placenta previa etc which are also Indications for Cs, arrive. Also
   14.1 % of the study population is aged above 35 which also contributes, since increasing age is also a risk
   factor for caesarean section. Out of the indications for Caesarean section 61% were due to macrosomia and
   fetal distress and rest were due to placenta previa nd other reasons like previous cs.


                                                                                                           12
TABLE 9

     Glycemic
     control            Frequency         Percent

     not controlled                54             38.0

     controlled                    88             62.0

     Total                        142         100.0

Only 62% of the cases studied were under glycemic control. I.e. Plasma blood sugar value below 95 mg
percentage.


TABLE 10

         Insulin
         taken        Frequency         Percent



         yes                 103            72.5

         no                   39            27.5

         Total               142           100.0




72.5% of the cases were taking insulin during pregnancy. 27.5% were under diet and exercise




                                                                                                       13
               FREQUENCIES OF PERINATAL MORBIDITIES


                       0.6

                       0.5

                       0.4

                       0.3

                       0.2

                       0.1

                        0




                                                    Figure 1


                               MORBIDITIES            CASES PERCENTAGE
                             Anomalies                   8        5.65%

                             Hypoglycemia               76        53.5%

                             Respiratory distress       56        39.4%

                             Growth abnormality         64        45.1%

                             Polycythemia                4         2.8%

                             APGAR <8                   64        45.1%

                             Dead                        1         .7%

                                              TABLE 11
Only 29.58% of the infants born were normal.70.42% of the infants born had either anomalies or
morbidities.RDS is found in 39.4% of infants which is 6 fold times than in general population. Mortality was
found to be .7% which shows a decrease compared to previous studies, may be due to better antenatal care.

                                                                                                         14
          PROPORTION OF CONGENITAL ANOMALIES

                                                      Frequency       Percent

                                    No anomaly               134          94.4

                                    Hydronephrosis                2         1.4

                                    VSD                           2         1.4

                                    ASD                           4         2.8

                                    Total                    142         100.0

                                                 TABLE 12




                                        Figure 2


Only 5.6% of the babies had congenital anomalies, of which 2.8% had Atrial Septal Defect and 1.4% had
Ventricular Septal Defect and 1.4% had Hydronephrosis. According to a previous study in India by
Mahathma Gandhi university rate of congenital anomaly was 2%. According to the study done by Diabetic
clinic in Birmingham there is a 3 fold chance for cong. Anomalies in diabetic pregnancies. Here the value
is almost in accordance with it. The most common anomalies are cardiovascular malformations and
lumbosacral agenesis followed by neural tube defects, Hydronephrosis, renal agenesis, duodenal or
anorectal atresia, holoprosencefaly, left colon syndrome. In our study also cardio vascular anomalies have
occurred at highest rate of 4.2% followed by Hydronephrosis (1.4%) as seen in figure 2. The rate could still
be higher since there is a chance of undiagnosed anomalies at the time of data collection.



                                                                                                         15
  DISTRIBUTION OF WIEGHT OF INFANTS BORN TO DIABETIC
                      MOTHERS




                                      FIGURE 3




                      Frequency    Percent

             Normal           78       54.9

             LGA              30       21.1

             SGA              34       23.9

             Total           142      100.0


        Table 13                                 Figure 4


54.9% of the babies were born with normal weight.45% babies had growth abnormality either SGA
(23.9%) or LGA (21.1%) as seen in figure 4. But with an average weight of 2.83. SGA babies weigh less
than 2.5kg and LGA babies weigh more than 3.5kg. here the average weight of a baby born to diabetic
mother is found to be 2.83kg even after high proportion of growth abnormalities(45.1%). This is due to the
fact that both SGA and LGA has occurred in similar proportions as represented in figure 3. According to
the study conducted by Tehran University of Medical Science, 29% were LGA and only 2% were SGA.
Increased rate of SGA may be due to increased rate of premature births. SGA is significant since these
babies are found to develop non insulin dependent diabetes later in their life as found in previous studies.
SGA could also result due to multiple pregnancy.in our study 5.5% of the mothers gave birth to twins, and
average birth weight of the twins had taken into consideration. Some reports suggest that overtreatment of
GDM resulting in sustained levels of glucose that are below the normal range may also lead to small-for-
gestational-age infants

                                                                                                         16
                 GESTATIONAL AGE OF INFANTS BORN




                                            Figure 5




                                                                                   Frequency    Percent

                                                                      premature            30      21.1%

                                                                      normal              112      78.9%

                                                                      Total               142     100.0%

                                                                                   Table 14




           Figure 6


21.1 % of babies were born premature .i.e before 37 weeks. And average gestational age isfound to be
36.96 weeks. as evident from figure 5 there is a shift in the peak to left compared to normal plot. In other
studies conducted else where also 14 – 36% of infants born to diabetic mothers were premature.
Prematurity mainly occurs due to the need for early delivery as there might arise the case of LGA and also
fetal distress that might result from high glycemic levels following uncontrolled diabetes. Premature babies
might as well occur in cases of multiple pregnancy and due to other obstetric complication requiring early
termination of gestation.


                                                                                                           17
          FREQUENCY DISTRIBUTION OF APGAR VALUES


                                APGAR
                                VALUE       Frequency   Percent

                                   0           1          .7

                                   5           8          5.6

                                   7           10         7.0

                                   8           42        29.6

                                   9           81        57.0

                                  Total       142       100.0


                                          TABLE 15




Only 57 % of the infants had APGAR value 9at 1 mnt. APGAR values shows a decrease which is an
indicator of neonatal morbidity with a mean APGAR of 8.27at 1 mnt. and 6.3% of the infants had APGAR
value less than 5 at 1 mnt as seen in table 15. Studies else where has shown 5% of infants born with
APGAR below 5 at 1mnt.




                                                                                                 18
   CONGENITAL ANOMALIES AND TYPE OF DIABETES


                                                     Type of diabetes

                                                 pre existing       gestational

                             anomalies   yes                    6                 2
  TABLE 16


                                         no                18               116




         CONGENITAL ANOMALIES* TYPE OF DIABETES CROSS TABULATION

            Chi         Degree of    Asymptomatic Relative               95% confidence
            square      freedom      significance risk                   interval
                                                                         lower      upper
            20.375      1            .000             5.583              3.104      10.044


  FIGURE 7




Congenital anomalies occur more among mothers having pre existing diabetes with a relative risk of 5.583.
according to our study 75% of the anomalies occurred in infants born to mothers with pre existing diabetes
and only 25% occurred in infants born to mothers with gestational diabetes. according to a study done in
Sweden in 1994 also proportion of anomalies occurring in mothers with pre existing diabetes were high ( 6
%) and occurrence of anomalies in gestational diabetes was only 2 % which were similar to the occurrence
in general population. In our study, out of 5.6% of anomalies , 4.2% occurred in mothers with pre existing
diabetes. and rate of occurrence of anomalies in GDM is only 1.4%. And there is a possibility that what
ever anomalies seem to occur in GDM may be due to previously undiagnosed type 2 DM.



                                                                                                       19
  CONGENITAL ANOMALIES AND GLYCEMIC CONTROL

                                                    Diabetes controlled or not

                                                    not controlled   controlled
       TABLE 17
                                 anomalies   yes          8              0

                                             no          46              88


                  CONGENITAL ANOMALIES* GLYCEMIC CONTROL CROSS TABULATION




                FIGURE 8


              Chi       Degree of     Asymptomatic            Relative         95% confidence
             square     freedom        significance             risk               interval
                                                                              lower        upper
             13.815          1               .000              2.913          2.305        3.682


100 % of the cases having anomalies occurred in mothers with uncontrolled diabetes. thus there is relation
between congenital anomalies and glycemic control with a relative risk of 2.913 and with a 95% confidence
interval of 2.305 to 3.682. from the previous studies and in the Textbook Of Obstetrics by Shiela
Balakrishnan also it states that there is a direct relationship between congenital anomalies and glycemic
control, as hyperglycemia, ketosis and toxic free radicals are the causes of congenital malformations




                                                                                                       20
RESPIRATORY DISTRESS AND PREMATURITY DUE TO DIABETES



                                                     premature babies

                                                   premature       normal     Total
      TABLE 18
                                respirato YES              26            30       56
                                ry
                                           NO                  4         82       86
                                distress

                                Total                      30           112      142
                              prematurity* respiratory distress cross tabulation
             Chi          Degree of        Asymptomatic Relative              95% confidence
             square       freedom          significance risk                  interval
                                                                              lower      upper
             35.524       1                .000             9.982             3.682      27.064




                                                FIGURE 9

 Increased proportion of respiratory distress is found to be associated to prematurity with a relative risk of
 9.982 and confidence interval of 3.682 to 27.064. there is 6 fold higher rate of respiratory distress in infants
 born to diabetic mothers than in general population. In addition to hyperinsulinemia which suppresses
 surfactant production and cause respiratory distress, prematurity also is found to contribute to higher rate of
 respiratory distress.

                                                                                                              21
              HYPOGLYCEMIA AND GROWTH ABNORMALITY


                          Growth abnormality * Hypoglycemia Cross tabulation
                                                                    hypoglycemia

                                                                   YES        NO        Total
TABLE 19
              growth abnormality   growth abnormality present            44        20           64

                                   no growth abnormality                 32        46           78

              Total                                                      76        66       142




            Chi           Degree of     Asymptomatic Relative            95% confidence
            square        freedom       significance risk                interval
                                                                         lower      upper
            10.862        1             .001               3.163         1.578      6.336




                                               FIGURE 10

 Growth abnormality and hypoglycemia are associated with a relative risk of 3.163 and p value less than
 .001. 44 out of 60 babies who had hypoglycemia had either of growth abnormality, SGA or LGA.
 According to a study conducted in Postgraduate Institute of Medical Education and Research, Chandigarh ,
 published in springfield.com, hypoglycemia is related to both LGA and SGA.it states about 25 % of SGA
 babies have hypoglycemia and 25-40% of babies with LGA have hypoglycemia according to
 emedicine.medscape.com.

                                                                                                      22
   PRE EXISTING DIABETES AND AGE OF MOTHERS

                                                                        age

                                                                 >35           <35

                             Type of diabetes pre existing              10            14

                                                                  41.7%         58.3%

                                                                  50.0%         11.5%
    TABLE 20                                    gestational             10           108

                                                                      8.5%      91.5%

                                                                  50.0%         88.5%




                                                   FIGURE 11

            Chi          Degree of       Asymptomatic Relative                95% confidence
            square       freedom         significance risk                    interval
                                                                              lower      upper
            18.158       1               .000                 4.917           2.302      10.50




There is greater risk of overt diabetes among elderly mothers(>35years) with a relative risk of 4.917 and p
value less than .001. according to a study published on Human Reproduction in Oxford journal.com,
pregnancy in mothers aged more than 35 years are associated with pre existing diabetes which is a
confounding factor for fetal morbidities.


                                                                                                          23
FACTORS WHICH WERE FOUND NOT TO HAVE STATISTICALLY
SIGNIFICANT ASSOSIATION WITH CONGENITAL ANOMALIES AND
PERINATAL MORBIDITIES


                                         TABLE 21


                                Chi       Degree of   Asymptomati      Relative    95% confidence
                                square    freedom     c significance   risk        interval
                                                                                   lower      upper
    APGAR below 8 and          1.619     1           .203             1.313      .863        1.996
     uncontrolled diabetes
    Hypoglycemia and           3.123     1           .07              1.319      .978       1.780
     uncontrolled diabetes
    Growth abnormality and     .014      1           .907             .978       .671       1.424
     uncontrolled diabetes
    Respiratory distress and   .062      1           .803             1.054      .696       1.598
     uncontrolled diabetes
    Anomalies in elderly       .835      1           .361             1.861      .520       6.659
     mothers
    APGAR value below 8 in     .000      1           .995             .997       .441       2.256
     elderly mothers
    Respiratory distress in    1.088     1           .297             1.536      .684       3.450
     elderly mothers
    Anomalies and presence     2.368     1           .124
     of other diseases
    APGAR below 8              4.120     1           .042             .499       .247       1.006
     &presence of other
     diseases
    Respiratory distress and
     presence of other          .009      1           .952             .970       .512       1.839
     diseases




                                                                                                  24
                                         CONCLUSIONS


1. 29.5% of the babies born were normal and 70.5% of the babies had either anomalies or other morbidities.
    Anomalies occurred in 5.6% infants, hypoglycemia in 53.5%, and respiratory distress in 39.4% growth
    abnormality in 45.1% and polycythemia in 2.5%. but the mortality rate was only .7%

2. It was found that congenital anomalies occur more among women with pre existing diabetes with a
   relative risk of 5.583and p value <.001.


3. There is a higher risk of getting anomalies in infants born to mothers with uncontrolled diabetes with a
   relative risk of 2.913 and p value <.001.

4. It is found that there is a greater risk of getting hypoglycemia in growth abnormalities with a relative risk of
     3.163 and p value <.001.


5. Relation between prematuriy and respiratory distress is also established with a relative risk of 3.163 and p
    value <.001 .


6. There is an increased risk of getting overt diabetes among elderly mothers (>35 years) with a risk of 4.917
   and p value <.001.




                                                                                                                25
                                   SUGGESTIONS



1.women having overt diabetes should be advised proper glycemic control before
conception and during gestation to reduce the risk of incidence of congenital anomalies
since it is found to occur more among mothers with pre existing diabetes.

2. There should be regular monitoring of the blood glucose level during gestation to reduce
incidence of congenital anomalies since it is found to be related more to uncontrolled
diabetes.

3. Elderly women planning to get pregnant should be screened for diabetes before
conception and should be advised for proper glycemic control to avoid incidence of
congenital malformations since women above 35 years are in greater risk for pre existing
diabetes which is a risk factor for anomalies.

4. Steroids can be used to avoid respiratory distress since prematurity is a concern among
babies born to diabetic mothers.




                                                                                             26
                                  BIBLIOGRAPHY



1. Park’s textbook of social and preventive edicine-20th edition

2. Textbook of obstetrics-Dr.Sheila Balakrishnan

3. Behrman, Kliegman, Arvin. Textbook of Pediatrics - 15th edition

4. www.wikipedia.com

5. www.medstudents.com

6. www.pubmed.gov

7. www.elsevier.com

8. www.docstoc.com

9. www.longwoods.com




                                                                     27
                                INDEX
Questionnaire

1. NAME:

2. AGE

3. IP NO.

4. DATE OF EXAMINATION

5. OCCUPATION 1.UNSKILLED 2.SKILLED

6. SOCIOECONOMIC STATUS        1.APL    2.BPL

7. WEIGHT (IN KG)       HEIGHT (IN CMS)

8. OBSTETRIC SCORE

9. PREVIOUS DELIVERY 1.CAESAREAN         2.NORMAL DELIVERY 3.NA

10. IF CAESAREAN, INDICATIONS
  1.MACROSOMIA   2.FETAL DISTRESS      3.PREVIOUS CS   4.OTHERS

11. CONDITION OF BABY OF PREVIOUS DELIVERY
  1.NORMAL 2.LGA 3.RDS 4.ANOMALIES 5.ABORTION 6.STILL BIRTH       7.OTHERS


12. HISTORY OF GESTATIONAL DIABETES MELLITUS 1.YES 2.NO

13. FAMILY HISTORY OF DIABETES MELLITUS 1.YES 2.NO


14HISTORY OF OTHER DISEASES
 1.HYPERTENSION 2.THYROID 3.CORONARY ARTERY DISEASE

15. TYPE OF PRESENT DELIVERY 1.CAESAREAN           2.NORMAL

16. INDICATIONS FOR CAESAREAN
1.MACROSOMIA   2.FETAL DISTRESS 3.PREVIOUS CS    4.OTHERS

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17. TYPE OF DIABETES 1.PRE EXISTING               2.GESTATIONAL

18. IF GESTATIONAL, DETECTED AT WHICH MONTH OF PREGNANCY

19. WHETHER DIABETES WAS CONTROLLED OR NOT 1.YES                   2.NO

20. WHETHER SHE WAS ON INSULIN DURING PRESENT PREGNANCY
1.YES     2.NO

21. IF IT WAS PRE EXISTING DIABETES, AT WHAT AGE WAS IT
DETERMINED?
1.0-10 YEARS 2.11-20 YEARS 3 .21-30 YEARS 4.31-40 YEARS      5.ABOVE 40 YEARS


22. WHAT TREATMENT WAS SHE ON
1.DIET AND EXERCISE2.ORAL HYPOGLYCEMICS 3.INSULIN


23. WEIGHT OF PRESENT BABY

24. APGAR SCORE

25. BORN AT WHICH WEEK OF GESTATION


MORBIDITIES

26.1. ANY GROWTH ABNORMALITY 1.LGA 2.SGA

2. RESPIRATORY DISTRESS1.YES 2.NO

3. HYPOGLYCEMIA 1.YES 2.NO

4. POLYCYTHEMIA 1.YES 2.NO


ANOMALIES

1. CVS
1. CARDIOMYOPATHY WITH VENTRICULAR HYPERTROPHY
2. OUTFLOW TRACT OBSTRUCTION
3. VENTRICULAR SEPTAL DEFECT
                                                                                29
4. ATRIAL SEPTAL DEFECT
5. TRANSPOSITION OF GREAT ARTERIES 6.COARCTATION OF AORTA

2. CNS

1. CAUDAL DYSPLASIA
2.ANENCEPHALY
 3.SPINA BIFIDA
 4.IMMATURE SUCKLING PATTERN

3. RENAL SYSTEM
1. HYDRONEPHROSIS
2.RENAL AGENESIS
 3.URETERAL DUPLICATION

4. EAR

5. GIT
1. DUODENAL OR ANORECTAL ATRESIA
 2.SMALL LEFT COLON SYNDROME

6. GENITOURINARY SYSTEM
1.AMBIGUOUS GENITALIA




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