There is a lot of uncertainty regarding screening for diabetes in pregnancy. While most authorities agree on OGTT at 24 to 28 weeks, diabetes screening during early pregnancy is a controversial issue with different organizations recommending different strategies. According to NICE guidelines (11), a 75 g 2-hour oral glucose tolerance test (OGTT) as soon as possible after booking visit (whether in the first or second trimester) is recommended in high risk groups. South Asian federation of endocrine societies (SAFES) recommends universal screening with 75-g OGTT during the booking visit (12). However, majority of patients in our study (88.8%) underwent post prandial blood sugar (PPBS) during the booking visit. A previous study conducted in Anuradhapura district in 2012 (8), used urinary sugar level which is not very reliable or accurate as the screening test. Compared to that we observed a marked improvement in diagnostic practice in our cohort. However, 2.8% of patients missed any form of blood sugar testing during the booking visit. Six mothers were diagnosed only during the third trimester.
American diabetes association (ADA) 2022 guideline recommends life style change and medical nutrition therapy as the first line therapy in gestational diabetes mellitus (13). More than 50% of our patients were managed with medical nutrition therapy alone. However, it advises caution on using metformin during pregnancy due to recent evidence suggesting Metformin may be associated with small for gestational age babies who have accelerated post-natal growth leading to higher body mass index (BMI) in childhood (14, 15). At the time of conducing this study this evidence was not available and therefore 36.7% of our patients were managed with metformin. In our study we didn’t observe an increase in low birth rate in mothers managed with metformin and MNT compared to those who were managed with MNT alone.
A previous study conducted among pregnant mothers in Colombo district from 2011 to 2015 evaluated pregnancy outcomes among patients with diabetes in pregnancy, gestational diabetes mellitus and hyperglycaemia in early pregnancy (16). 572 patients were included in the final analysis and 2 intra uterine deaths were reported. 23.6% (n = 135) had birth weight more than 3.5 kg. 27.7% (n = 90) had birth weight less than 2.5 kg. Maternal complications were reported in 21.1% and neonatal complications were reported in 25.8%. Our study was conducted in district general hospital Vavuniya, which is a rural district still recovering from the impact of decades of civil war. Despite that our cohort of pregnant patients had very low rates of maternal and neonatal complications. This is due to the excellent public health program in Sri Lanka which delivers maternal care with the collaboration of different health care workers at different levels from primary care to tertiary care.
Studies conducted in Pakistan (17) and Bangladesh (18) have reported macrosomia rates of 13% and 24% respectively. Studies conducted in different parts of India have reported macrosomia rates of 32% (19), 4% (20), 28% (21), 27.6% (22) and 16.2% (23). Still birth rate was 4.8% in the study by Wahi et al (24). Low birth weight was reported in 21.8% (20), 8.2% (22) and 14.2% (23) in studies conducted in India. Rate of macrosomia (13.3%) and low birth weight (5.2%) was lower in our cohort compared to most of the above studies.
Caesarian section rate was only 25.9% in the study conducted in Pakistan by Akhter et al. Saxena et al reported a caesarian section rate of 42% among patients with gestational diabetes mellitus.
Although our cohort had a higher rate of caesarian sections, 63.3% of caesarian sections were elective and most of the caesarian sections were due to past caesarian section which is presumably unrelated to the diagnosis or management of diabetes in this pregnancy.
A history of gestational diabetes mellitus increases the risk of type 2 diabetes mellitus in future (24). Furthermore, some of these mothers have undiagnosed pre-existing diabetes. A sri lankan study showed that 18.6% of mothers with GDM had diabetes at 1-year post-partum follow up and 47.5% had abnormal glucose tolerance (25). Studies conducted in Turkey (26), France (27) and USA (28) have reported post-partum screening rates of 47.4%, 65% and 27% respectively. In our cohort post-partum screening rate was 86.7%. While this is better than the above studies, we have missed screening in 13.3%. If these mothers are not followed up in the post-partum period they can go to the next pregnancy with poor glycaemic control and diabetes related complications which will significantly increase the risk of maternal and foetal/neonatal complications. In Sri Lankan culture mothers return to their parents’ home after delivery. This may be the reason why they were lost to follow up. Educating the mothers during ante natal period may be an important step to increase post-partum screening rates. Furthermore, a mechanism needs to be established where public health midwife of the area mother is visiting can trace her and refer her for screening.
To our knowledge this is the largest study conducted in a rural district of Sri Lanka which describes diagnosis, management and maternal and neonatal outcomes of diabetes in pregnancy. This is the first Sri Lankan study that describes post-partum screening rates.
However, a control group was not available to allow us to assess associations and determinants of hyperglycaemia in pregnancy. Furthermore, this data represents only those who delivered at the tertiary care hospital and may not be representative of the whole community.