Okan BAKINER, Emre BOZKIRLI, Hülya SERİNSÖZ, Çağla SARITÜRK, Eda ERTÖRER

Gestasyonel Diyabeti Olan Gebelerin Prenatal ve Perinatal Özelliklerinin Postpartum Erken Glukoz Metabolizması Üzerine Etkileri

Amaç: Gestasyonel diyabetes mellitus( GDM) olan ve postpartum erken dönemde bozulmuş açlık glukozu (BAG) ve bozulmuş glukoz toleransı (BGT) tanısı alan olgularda antenatal ve perinatal risk faktörleri açısından fark olup olmadığını araştırmak. Materyal ve Metod: Obstetrik polikliniğinde spontan gebelik takibinde olup GDM tanısı konan ve öyküsünde bilinen glukoz anormalliği olmayan olgular çalışmaya alındı.Olguların geçmişte GDM varlığı, makrosomik bebek doğurma öyküsü ve ailesinde tip-2 diyabet varlığı sorgulandı.Yaş,prekonsepsiyonel ve tanıda vücut-kitle indeksi (VKİ), tanıya kadar alınan kilo, kan basınçları ile tanıdaki HbA1C düzeyleri kaydedildi. Takipte insülin tedavisi başlananlar kaydedildi. Doğum haftası, doğuma kadar alınan toplam kilo, bebeğin doğum kilosu kaydedildi. Postpartum 6. Haftada OGTT uygulandı. Olgular postpartum normal, bozulmuş açlık glukozu(BAG) ve bozulmuş glukoz toleransı (BGT) olarak gruplandırıldı. İstatistiksel analizlerle antenatal ve perinatal özelliklerin doğum sonrası glukoz anormalliklerine etkisi olup olmadığı incelendi. Bulgular:Çalışmayı tamamlayan 80 olgudan postpartum 6. Haftada yapılan OGTT sonrasında %58,7 si normal glukoz metabolizması (n=47),%13,7 "si BAG ( n=11) ve %27,5 "i BGT (n=22) olarak saptandı. Ailesinde diyabet olanlarda BAG görülme sıklığının normallere ve BGT grubuna göre anlamlı artmış olduğu gözlendi (p=0,042). Yine takipte insülin başlananlarda (n=41) BAG görülme sıklığının arttığıbelirlendi (p=0,039). Prenatal ve perinatal diğer özelliklerden hiçbirisi üç gruptada farklılık göstermedi. Yapılan multivaryant analiz sonrası ailede diyabet varlığının postpartum erken dönem BAG için bağımsız risk faktörü olduğu tespit edildi (p=0,037). Risk analizinde ailesinde diyabet olanların (%25-80 güven aralığında) 1,7 kat artmış doğum sonrası BAG riskine sahip olduğu saptandı. Sonuç: Ailede diyabet varlığı gestasyonel diyabetik olgularda postpartum erken dönemde BAG varlığı için bir risk faktörü olabilir.

Anahtar Kelimeler:

Gestasyonel diyabet, bozulmuş açlık glukozu, bozulmuş glukoz toleransı

Assessment of prenatal and perinatal characteristics of pregnants with gestationel diabetes mellitus who have postnatal glucose abnormalities

Purpose: To examine the difference in terms of prenatal and perinatal characteristics between gestational diabetic (GDM) cases diagnosed with impaired fasting glucose (IFG)and impaired glucose tolerance (IGT) during early postpartum period. Material and Methods: Cases who had no history of any glucose metabolism disorder and diagnosed as GDM due to American Diabetes Association (ADA) criteria were included. Subjects were inquired for pregestational characteristics(glucose abnormality in previous pregnancies, birth of macrosomic baby and history of diabetes in a first-degree relative), prenatal characteristics (age, body mass index BMI), features at diagnosis (BMI,weight-gain ,blood pressure and HbA1C), and perinatal characteristics (birth week and baby birth weight) were recorded. Oral glucose tolerance test (OGTT) was reperformed in the 6th postpartum week. Effects of pregestational, prenatal and perinatal features on postpartum glucose abnormalities were analysed. Results: Out of 80 cases who completed the study 58.7%(n=47) had normal glucose metabolism, 13.7%( n=11) had IFG and 27.5%(n=22) had IGT. No difference was found between pregestational, prenatal , perinatal characteristics, features at the time of diagnosis and postpartum OGTT results. Incidence of IFG in postpartum OGTT for those who had diabetes in a first degree relative was elevated when compared with other cases(p=0,042). The difference was preserved after adjustment for other characteristic features with multivariate analysis (p=0,037). Conclusion: Presence of diabetes in a first degree relative may be a risk factor for postnatal early IFG. In our study other pregestational, prenatal, perinatal factors and features at diagnosis didn"t affect early postpartum glucose metabolism.

Keywords:

Gestational diabetes, impaired fasting glucose, impaired glucose tolerance,

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American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2005;28:37-42.
Kjos SL, Buchanan TA, Greenspoon JS, Montoro M,Bernstein GS, Mestman JH. Gestational diabetes mellitus: the prevalence of glucose intolerance and diabetes mellitus in the first two months post partum. Am J Obstet Gynecol. 1990; 163:93-8.
Catalano PM, Vargo KM, Bernstein IM, Amini SB. Incidence and risk factors associated with abnormal postpartum glucose tolerance in women with gestational diabetes. Am J Obstet Gynecol. 1991; 165:914-9.
Dacus JV, Meyer NL, Muram D, Stilson R, Phipps P, Sibai BM. Gestational diabetes: postpartum glucose tolerance testing. Am J Obstet Gynecol. 1994; 171:927-31.
Pallardo F, Herranz L, Garcia-Ingelmo T, Grande C, Martin-Vaquero P, Janez Met al. Early postpartum metabolic assessment in women with prior gestational diabetes. Diabetes Care. 1999; 22:1053
Di Cianni G, Miccoli R, Volpe L, Lencioni C, Del Prato S. Intermediate metabolism in normal pregnancy and in gestational diabetes. Diabetes Metab Res Rev. 2003; 19:259-70.
Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care. 2002;25:1862-8.
Ogonowski J, Miazgowski T. The prevalence of 6 weeks postpartum abnormal glucose tolerance in Caucasian women with gestational diabetes. Diabetes Res Clin Pract. 2009; 84:239-44.
World Health Organization. Definition, diagnosis, and classification of diabetes mellitus and its complications. Report of a WHO Consultation. Geneva: World Health Organization,1999.
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 1997; 20:1183–
American College of Obstetricians and Gynecologists. Practice bulletin. Clinical management uidelines for obstetrician-gynecologists. Gestational diabetes. Obstet Gynecol. 2001; 98:525–
National Institute for Health and Clinical Excellence. Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the postnatal period. Clinical guideline 63. London: NICE, 2008.
Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S et al. Clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association. Can Med Assoc J. 1998; 159:1–29.
Metzger BE, Buchanan TA, Coustan DR, de Leiva A, Dunger DB, Hadden DR et al. Summary and recommendations of the Fifth International Workshop—Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007; 30:251–60.
Kitzmiller JL, Dang-Kilduff L, Taslimi MM. Gestational diabetes after delivery. Short-term management and long-term risks. Diabetes Care. 2007;30: 225-35.
Greenberg LR, Moore TR, Murphy H. Gestational diabetes mellitus: antenatal variables as predictors of postpartum glucose intolerance. Obstet. Gynecol. 1995; 86 : 97–101.
Agrawal MM, Punnose J, Dhatt GS. Gestational diabetes:implication of variation in post-partum follow-up criteria.Eur J Obstet Gynecol. 2004; 113: 149–53.
Russell MA, Phipps MG, Olson CL, Welch HG, Carpenter MW. Rates of postpartum glucose testing after gestational diabetes mellitus. Obstet. Gynecol. 2006; 108: 1456–62.
Kjos SL, Peters RK, Xiang A, Henry OA, Montoro M, Buchanan TA. Predictingfuture diabetes in Latino women with gestational diabetes: utility of early postpartumglucose tolerance test. Diabetes. 1995; 44:586–591
Henry OA, Beischer NA. Long-term implications of gestational diabetes for themother. Baillières Clin Obstet Gynaecol. 1991; 5:461–84
Metzger BE, Bybee DE, Freinkel N, Phelps RL, Radvany R, Vaisrub N: Gestational diabetesmellitus: correlations between the phenotypic and genotypic characteristics of the mother and abnormal glucose tolerance during first year postpartum. Diabetes. 1985; 34:111–5.
Coustan DR, Carpenter MW, O’Sullivan PS, Carr SR. Predictors of subsequent disordered glucose metabolism. Am J Obstet Gynecol. 1993; 168:1139–
Dornhorst A, Bailey PC, Anyaoku V, Elkeles RS, Johnston DG, Beard RW. Abnormalities of glucose tolerance following gestational diabetes. Quart J Med. 1990; 7:1219–28.
Buchanan TA, Xiang A, Kjos SL, Lee WP, Trigo E, Nader I et al.Gestational diabetes: antepartum characteristics that predict postpartum glucose intolerance and type 2 diabetes in Latino women. Diabetes. 1998;4: 1302 –10.
Larsson G, Spjuth J, Ranstam J, Vikbladh I, Saxtrup O, Astedt B. Prognostic significanceof birth of a large infant for subsequent development of maternal noninsulindependent diabetes mellitus: a prospective study over 20–27 years. Diabetes Care. 1986; 9:359–64
Bartoli E, Fra GP, Carnevale Schianca GP.The oral glucose tolerance test (OGTT) revisited.Eur J Intern Med. 2011; 22:8-12.
Butte NF. Carbohydrate and lipid metabolism in pregnancy: normal compared with gestational diabetes mellitus. Am J Clin Nutr. 2000; 71:1256-61
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2011; 34:62.
Thompson DJ, Porter KB, Gunnells DJ, Wagner PC, Spinnato JA et al. Prophylactic insulin in the management of gestational diabetes. Obstet Gynecol. 1990; 75:960
American Diabetes Association.The American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many years. Introduction. Diabetes Care. 2009; 32:1-2
Schaeffer-Graf UM, Buchanan TA, Xiang AH, Peters RK, KjosSL. Clinical predictors for a high risk for the development of diabetes mellitus in the early puerperium in women with recent gestational diabetes mellitus, Am. J. Obstet. Gynecol. 2002;186: 751–
Ekelund M, Shaat N, Almgren P, Groop L, Berntorp K. Prediction of postpartum diabetes in women with gestational diabetes mellitus. Diabetologia. 2010; 53:452-7.
Carocha A, Rijo C, Amaral N, Aleixo F, Rocha T.Diabetes in pregnancy - postpartum screening. Acta Med Port. 2012; 25:165-8.
Löbner K, Knopff A, Baumgarten A, Mollenhauer U, Marienfeld S, Garrido-Franco M et al. Predictors of postpartum diabetes in women with gestational diabetes mellitus. Diabetes. 2006; 55:792-7.
Kahn SE. The relative contributions of insülin resistance and beta-cell dysfunction to the pathophysiology of type 2 diabetes. Diabetologia. 2003; 46:3–19
Buchanan TA: Pancreatic beta-cell defects in gestational diabetes: implications for the pathogenesis and prevention of type 2 diabetes.J Clin Endocrinol Metab. 2001; 86:989–93
Vrbikova J, Bendlova B, Vankova M, Dvorakova K, Grimmichova T, Vondra K et al. Beta cell function and insulin sensitivity in women with polycystic ovary syndrome: influence of the family history of type 2 diabetes mellitus. Gynecol Endocrinol. 2009; 25:59760
Verrotti A, Chiarelli F, Capani F, Morgese G. Prediabetes: genetic, immunological and metabolical aspects.Panminerva Med. 1993; 35:179-85.
Osei K, Gaillard T, Schuster DP.Pathogenetic mechanisms of impaired glucose tolerance and type II diabetes in African-Americans. The significance of insulin secretion, insulin sensitivity, and glucose effectiveness. Diabetes Care. 1997; 20:396-404.
Del Prato S, Marchetti P.Beta- and alpha-cell dysfunction in type 2 diabetes. Horm Metab Res. 2004;36:775-81.
Hunt KJ, ConwayDL, Who returns for postpartum glucose screening following gestational diabetes mellitus. Am J Obstet Gynecol 2008;198: 404-6.
Yazışma Adresi / Address for Correspondence: Dr. Okan Bakıner Başkent Üniversitesi Tıp Fakültesi Adana Uygulama ve Araştırma Hastanesi Endokrinoloji ve Metabolizma Hastalıkları Kliniği Yüreğir/ADANA e-mail; okanbakiner@mynet.com geliş tarihi/received :26.02.2013 kabul tarihi/accepted:01.04.2013