TEMPLATE DESIGN © Diet Plus Insulin Compared to Diet Alone In The Treatment of GDM Mothers in HUSM, Kelantan. Wan Faizah M, Nik Ahmad Zuky NL, Mohd Pazudin I, Che Anuar CY Department of Obstetric and Gynecology, School of Medical Science, USM, Kelantan. Malaysia Objectives Study Hypothesis Women with gestational diabetes mellitus (GDM) treated with diet and insulin has better fetal and maternal outcomes as compared to patients treated with diet alone General objective To compare the pregnancy and neonatal outcome in the patients treated with diet plus insulin versus diet alone in the treatment of GDM in HUSM Specific objectives 1. To determine the proportion of GDM women treated with diet plus insulin and those managed with diet therapy alone. 2. To determine the maternal factors associated with the insulin requirement. 3. To compare the maternal (i.e. gestational hypertension without proteinuria, preeclampsia, polyhydramnios, caesarean delivery, post-partum hemorrhage) and neonatal (i.e. prematurity, fetal macrosomia, Apgar score < 7 at 5 minutes, fetal hypoglycemia, NICU admission) outcome of those treated with diet plus insulin versus those treated with diet alone in GDM mothers. Methods Methodology It was a prospective cohort study, conducted in Hospital Universiti Sains Malaysia (HUSM) from May 2010 till May 2011, involving 198 pregnant women diagnosed GDM who attended to Antenatal Clinic and admitted to antenatal ward HUSM and fulfilled the inclusion and exclusion criteria. Approved by the Research and Ethical Committee, School of Medical Sciences, USM on February Inclusion criteria 1.Pregnant mother diagnosed with GDM ( WHO criteria 1999) 2. Singleton pregnancy Exclusion criteria 1. Women with known pregestational diabetes. 2. Women with Hypertensive disorder in pregnancy. 3. Women with other preexisting medical illness such as chronic renal disease, SLE, Thyroid disease, epilepsy, blood disorder. 4. Delivered in centre other than HUSM Flow of Study Results 1. Out of 198 participants, 29.8% ( n= 59 ) required insulin whille 70.2% ( n=139 ) of participants required diet only therapy to achieve normoglycemia Table 1 : Associations of maternal factors with insulin requirements in the treatment of GDM 3. Table 2: Incidence of maternal and fetal complications in GDM mothers treated with insulin plus diet therapy as compared to diet only Conclusions References % of GDM women required insulin in order to achieve normoglycemia while 70.2% of study populations required diet only to achieve normoglycemia 2. There are statistically significant association between multiparity, maternal obesity, previous history of GDM, previous history of insulin injections, POG at diagnosis of GDM and HbA1c value at the study entry with the insulin requirements in the GDM mothers. Thus it is possible to predict requirements of insulin in the GDM mothers. 3. There is statistically significant reduction in the incidence of fetal macrosomia in the insulin plus diet group as compared to diet only group ( 10.2% vs 23.0% ). 4. Treatment with insulin plus diet were associated with slight reduction in the incidence gestational hypertension ( 6.8% vs 12.9%), incidence of PE (3.4% vs 6.5%), incidence of polyhydramnios (8.5% vs 16.5%), incidence of PPH ( 1.7% vs 4.3% ), incidence of neonatal hypoglycemia ( 8.6% vs 17.3%) and incidence of poor Apgar score (1.7% vs 2.2%) compared to diet alone in patients with GDM. 5.The incidence of Caesarean deliveries was similar in both groups ( 30.5% vs 30.2%) 6.There were slight increased in the incidence of prematurity ( 6.8% vs 4.3%) and NICU admission ( 20.7% vs 18.7%) in the diet plus insulin group compared to diet alone group. 7. It can be concluded that insulin is an effective drug as it is associated with reduction in the incidence of adverse fetal and maternal outcomes if compared to diet alone in the management of GDM mothers. OPTIONAL LOGO HERE 1.CFan, Z.T., Yang, H.X., Gao, X.L.(2006). Pregnancy outcomes in GDM. International Journal of Obstetric and Gynecology, 94, Graffida, F.M.A., Atallah, A.N.(2003).Diet plus insulin compared to diet alone in the treatment of GDM: A systemic review. Journal of medical & biological research, 36, National Institute for Health and Clinical Excellence (NICE), Diabetes in Pregnancy, March 2008 ( revised reprint July 2008). 4.Gonzalez-Quintero,V.H., Istwan, N.B., Rhea, D.J.,De laTorre et al.(2008). Antenatal factors predicting subsequent need for insulin treatment in women with GDM. J Womens Health (Larchmt), 17 (7),1183—1187. Factors Insulin requirements { n (%) } P value 1. Maternal age ( years) <20 20 to 34 ≥35 1 ( 1.7) 35 (59.3) 23 (39.0) Parity Nulliparity Para 1 to 5 Para 6 and above 11 ( 18.6 ) 41 ( 69.5 ) 7 ( 11.9 ) BMI at booking ( kg/m² ) < to to ≥ ( 13.6 ) 32 ( 54.2) 19 ( 32.2) Family history of DM Yes No 33 ( 55.9 ) 26 ( 44.1) Previous history Of GDM Yes No 30 ( 50.8 ) 29 ( 49.2) < Prior history of insulin therapy Yes No 10 ( 16.9 ) 49 ( 83.1) Prior history of macrosomic baby Yes No 12 ( 20.3 ) 47 ( 79.7 ) POG at diagnosis of GDM ≤ to 28 > ( 25.4 ) 44 ( 74.6 ) HbA1c level at study entry < 7 7 to 8 >8 39 ( 66.1 ) 14 ( 23.7 ) 6 ( 10.3 ) < Parameters Diet only group ( n=139) Insulin plus diet group (n= 59) Total (n=198) P value Gestational hypertension 18 ( 12.9%)4 (6.8%)22 (11.1%)0.206 Preeclampsia9 (6.5%)2 ( 3.4%)11 ( 5.6%)0.386 Polyhydramnios23 (16.5%)5 ( 8.5%) 28 (14.1%)0.136 Premature labour 6 (4.3%)4 ( 6.8%)10 ( 5.1%)0.469 Fetal macrosomia 32 (23.0%)6 (10.2%)38 (19.2%)0.036 Caesarean section 42 (30.2%)18 (30.5%)60 (30.3%)0.967 PPH6 (4.3%)1 ( 1.7%)7 ( 3.5%)0.361 Apgar score < 7 at 5 minutes 3 ( 2.2%)1 ( 1.7%)4 (2.0%)0.844 Neonatal hypoglycemia 24 ( 17.3%)5 ( 8.6%)29 (14.7%)0.119 NICU admission26 ( 18.7%)12 ( 20.7%)38( 19.3%)0.748 REFERENCE POPULATION All antenatal mothers with GDM and fulfilled criteria. Referral to dietician for dietary advice 2. Blood taken for HbA1c at study entry 2. Diabetic diet therapy for 2 weeks 3. Pre-prandial BSP were taken after 2 weeks on dietary therapy. DIET ONLY GROUP BSP measured 2 weekly. Uncontrolled BSP – 2 participants excluded from the study, 2 delivered elsewhere. BP monitoring and urine test for proteinuria DIET PLUS INSULIN GROUP BSP measured 2 weekly Uncontrolled BSP- adjust insulin accordingly BP monitoring and urine test for proteinuria Normal BSP n=143Abnormal BSP n =59 DELIVERY 1.Data on delivery (139 participants from diet only group and 59 participants from diet plus insulin group) and maternal outcomes obtained from delivery records. 2.Data on fetal outcomes obtained from delivery record.