Carbohydrate intolerance in pregnancy: incidence and neonatal outcomes

Evelyne Rey, MD, MSc
Danielle Monier, MD
Marie-Chantal Lemonnier, MD

Clin Invest Med 1996; 19 (6): 406­15.

[résumé]

Dr. Rey is with the Department of Obstetrics and Gynecology, Hôpital Sainte-Justine, and the Department of Medicine, Hôpital Hôtel-Dieu de Montréal; Dr. Monier is with the Department of Medicine and Dr. Lemonnier is with the Department of Obstetrics and Gynecology, Hôpital Maisonneuve­Rosemont, Montreal, Que.

(Original manuscript submitted Nov. 23, 1995; received in revised form Apr. 12, 1996; accepted Apr. 30, 1996)

Paper reprints may be obtained from: Dr. Evelyne Rey, Department of Obstetrics and Gynecology, Hôpital Sainte-Justine, 3175 Côte Sainte-Catherine Rd., Montreal QC H3T 1C5; fax 514 345-4648

Contents

Abstract

 Objective: To determine the incidence of carbohydrate intolerance during pregnancy and its impact on neonatal outcomes, which have not been formally established in Canada.

Design: Chart review.

Participants: All 1432 women who delivered a single newborn in the months of May and September 1992 in Hôpital Sainte-Justine, Montreal, Hôpital Maisonneuve­Rosemont, Montreal, and Centre hospitalier de Rouyn-Noranda, Rouyn, Que. Women with multiple births or pre-existing diabetes mellitus were excluded.

Outcome measures: Carbohydrate intolerance, including gestational glucose intolerance (one abnormal result of an oral glucose tolerance test) and gestational diabetes mellitus (two or more abnormal results of the test); neonatal outcomes, including birth weight, hypoglycemia and hyperbilirubinemia.

Results: Of the 1074 women tested, 72 (6.7%) had gestational glucose intolerance and 98 (9.1%) had gestational diabetes mellitus. Of those women with carbohydrate intolerance, 120 were treated and 50 were not. Women who were not treated had higher rates of poor neonatal outcomes than women without carbohydrate intolerance (p < 0.05) or than women with carbohydrate intolerance who had received treatment (p < 0.05). Women who were not treated had higher rates of newborns with a birth weight of more than 4000 g (18.0%), large-for-gestational-age newborns (20.0%) and newborns with hypoglycemia (24.0%) or hyperbilirubinemia (40.0%) than women without carbohydrate intolerance (for whom the rates were 6.7%, 10.0%, 10.0% and 22.8%, respectively) or than women with carbohydrate intolerance who received treatment (for whom the rates were 6.7%, 6.7%, 10.0% and 21.7%, respectively).

Conclusions: In this population, carbohydrate intolerance during pregnancy is a significant problem. Not only is the incidence rate higher than that usually estimated, but the impact on neonatal morbidity is also significant.

Résumé

 Objectif : Déterminer l'incidence de l'intolérance aux glucides durant la grossesse et son impact sur les nouveau-nés, ce qui n'a jamais été officiellement établi pour le Canada.

Conception : Révision de dossiers.

Sujets : Toutes les femmes (n = 1432) ayant accouché d'un seul nouveau-né en mai ou en septembre 1992, à l'Hôpital Sainte-Justine et à l'Hôpital Maisonneuve­Rosemont de Montréal, et au Centre hospitalier de Rouyn-Noranda, à Rouyn (Qué.). Les femmes ayant des grossesses multiples ou souffrant de diabète sucré ont été exclues.

Mesures des résultats : Chez la mère, l'intolérance aux glucides, comprenant l'intolérance au glucose durant la grossess (une valeur anormale à l'hyperglycémie orale provoquée) et le diabète gestationnel (deux ou plusieurs valeurs anormales à l'hyperglycémie orale provoquée); chez le nouveau-né, poids à la naissance, hypoglyclémie et hyperbilirubinémie.

Résultats : Parmi les 1074 femmes qui ont été testées, 72 (6,7 %) ont présenté une intolérance au glucose durant la grossesse et 98 (9,1 %), un diabète gestationnel. De ces 170 femmes, 120 ont été traitées et 50 ne l'ont pas été. Les femmes qui n'ont pas été traitées ont présenté des taux plus élevés de nouveau-nés macrosomes (20,0 %), pesant plus de 4000 g (18,0 %), présentant une hypoglycémie (24,0 %) ou une hyperbilirubinémie (40,0 %) que les femmes sans intolérance aux glucides (10,1 %, 6,7 %, 10,0 % et 22,8 %; p < 0,05), et que les femmes qui ont été traitées (6,7 %, 6,7 %, 10,0 % et 21,7 %; p < 0,05).

Conclusions : Dans notre population, l'intolérance aux glucides durant la grossesse est une complication non négligeable, tant par son incidence -- plus élevée qu'on ne l'estime généralement -- que par son impact sur la morbidité néonatale.

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Introduction

 Carbohydrate intolerance in pregnancy, especially gestational diabetes mellitus, is controversial. Issues debated in the literature include the relation between gestational diabetes mellitus and perinatal mortality,[1-5] congenital malformations,[6,7] macrosomia[5,8-11] and neonatal metabolic problems.[12,13] There is also a lack of agreement on whether treatment improves perinatal outcomes.[5,8,14-16] The disagreement about gestational diabetes mellitus is illustrated by the inconsistent advice from the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Canadian Task Force on the Periodic Health Examination. The SOGC recommends universal screening and treatment for gestational diabetes mellitus,[17] whereas the task force does not.[18] The discrepancies among previous reports may be explained by the lack of knowledge about the impact of untreated gestational diabetes mellitus. Moreover, the impact of gestational diabetes mellitus in a given population is related to its incidence. If the incidence of gestational diabetes mellitus is low, screening and treatment will have little effect. The incidence rates vary considerably among countries, and rates from 1.4% to 10% have been reported.[19-25] In Canada, the incidence of gestational diabetes mellitus has never been formally established, although a rate of 3% has been quoted.[17,18] In a recent report from Toronto, an incidence rate of 3.8% was observed.[26] However, this study was not formally designed to establish the incidence of gestational diabetes mellitus.

The purpose of this study was to establish the incidence of carbohydrate intolerance in pregnancy and to study its impact on neonatal outcomes in a sample of Canadian women.

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Methods

Subjects

This observational study involved three institutions: Hôpital Sainte-Justine, Montreal, Hôpital Maisonneuve­Rosemont, Montreal, and Centre hospitalier de Rouyn-Noranda, Rouyn, Que. These hospitals provide primary care to the local population and tertiary care for patients across the province. In the Montreal hospitals, women were followed mainly by obstetricians, and in Centre hospitalier de Rouyn-Noranda, they were followed by general practitioners.

We studied the charts of all women who delivered during two months, May and September 1992, chosen at random. Women referred after 26 weeks' gestation, women who had multiple births and women with pre-existing insulin-dependent or non-insulin-dependent diabetes mellitus were excluded.

Carbohydrate intolerance

The three institutions used the 50-g, 1-h glucose challenge test, performed between 24 and 28 weeks' gestation, to screen for carbohydrate intolerance and the 100-g, 3-hour oral glucose tolerance test to diagnose the condition. Unlike the other institutions, which measured the glucose value in the two tests from plasma venous blood, Hôpital Sainte-Justine measured glucose values from plasma capillary blood. Therefore, this institution used its own criterion for intolerance: a value two standard deviations from the mean result of the oral glucose tolerance test in the local population. Hôpital Maisonneuve­ Rosemont and Centre hospitalier de Rouyn-Noranda used the criteria recommended by the Society of Obstetricians and Gynaecologists of Canada and various US societies.[17,27] The oral glucose tolerance test was performed if the patient's glucose level, determined by the glucose challenge test, was greater than 8.9 mmol/L, in Hôpital Sainte-Justine, and greater than 7.8 mmol/L, in Hôpital Maisonneuve­Rosemont and Centre hospitalier de Rouyn-Noranda. The oral glucose tolerance test was performed when patients were fasting, after they had eaten a diet containing at least 150 g of carbohydrates per day for 3 days. In Hôpital Sainte-Justine, the upper normal values obtained in the oral glucose tolerance test, performed before 26 weeks' gestation, were: fasting, 5.3 mmol/L; at 1 h, 10 mmol/L; at 2 h, 8.9 mmol/L; and at 3 h, 7.8 mmol/L; and values when the test was performed during and after 26 weeks' gestation were: fasting, 5.6 mmol/L; at 1 h, 11.1 mmol/L; at 2 h, 9.2 mmol/L; and at 3 h, 8.3 mmol/L. In Hôpital Maisonneuve­Rosemont and Centre hospitalier de Rouyn-Noranda the oral glucose tolerance test was considered abnormal if one or more of the following values was met or exceeded: fasting, 5.8 mmol/L; 1 h, 10.6 mmol/L; 2 h, 9.2 mmol/L; and 3 h, 8.1 mmol/L. These glucose values were measured by the glucose oxidase method in all three institutions.

For the purposes of this study, carbohydrate intolerance includes gestational glucose intolerance (one abnormal result of the oral glucose tolerance test) and gestational diabetes mellitus (two or more abnormal results of the test). Women who did not undergo the glucose challenge test or the oral glucose tolerance test were classified as "no diagnosis." Women who had normal results of the glucose challenge test or the oral glucose tolerance test were classified as controls.

Carbohydrate intolerance follow-up

Women who were not treated did not receive special care for carbohydrate intolerance. These women were not prescribed any dietary therapy, did not meet with a dietician or a nurse who specialized in diabetes mellitus, did not have any glucose-level measurement during pregnancy and did not have a notice concerning carbohydrate intolerance on their diagnostic sheet. Women who were treated received special care for carbohydrate intolerance. They were prescribed a diet of 147 kJ/kg (105 kJ/kg for obese women) containing no refined carbohydrates and consisting of 45% complex carbohydrates, 35% fats and 20% proteins, eaten as part of three meals and four snacks a day. In Hôpital Sainte-Justine and Hôpital Maisonneuve­Rosemont, women with gestational diabetes mellitus were assigned to self-monitoring of blood glucose levels with the use of a memory meter. In Hôpital Sainte-Justine and Hôpital Maisonneuve­Rosemont, the fasting and 1-hour postprandial glucose levels of women with gestational glucose intolerance were assessed every 2 weeks. In Centre hospitalier de Rouyn-Noranda, all women with an abnormal result of the oral glucose tolerance test were followed, and their fasting glucose level was determined every 2 weeks. Target glucose levels were 5.3 mmol/L, fasting, and 7.8 mmol/L, 1 hour after eating. Women with results higher than these received insulin therapy. The insulin dose was individually adjusted to allow each woman to reach the target glucose levels. In Hôpital Sainte-Justine and Hôpital Maisonneuve­Rosemont, an internist or an endocrinologist was responsible for management of carbohydrate intolerance, and, in Centre hospitalier de Rouyn-Noranda, a general practitioner was responsible.

Data

Data on the mothers were obtained from the charts by a research nurse. Obesity was defined as a pregravid body mass index (BMI) greater than 27 kg/m2. Family history of diabetes mellitus was defined as diabetes mellitus in first-degree relatives. Chronic diseases included chronic hypertension, asthma, thyroid disease and inflammatory bowel disease. Birth weight was corrected for gestational age and sex, according to a Canadian chart.28 Small-for-gestational-age (SGA) newborns included those with a birth weight lower than the 10th percentile, and large-for-gestational-age newborns (LGA) included those with a birth weight higher than the 90th percentile. Newborn hypoglycemia was defined as a blood glucose level, taken from heel capillary blood during the first 72 hours of life, of less than 1.7 mmol/L in term newborns and less than 1.1 mmol/L in preterm ones. Newborn hyperbilirubinemia was defined as a bilirubin level greater than 170 mmol/L in the first 24 hours of life, or greater than 205 mmol/L in the second day of life, or greater than 240 mmol/L in the third day of life.

Statistical analysis

Data were analysed with the use of SPSS software (version 4.0, SPSS Inc., Chicago). Continuous variables were analysed with the use of Student's t-test or Mann­Whitney test. Categorical variables were analysed with the chi2 test. Multiple logistic regression analysis (a stepwise forward model) was used to determine the risk factors for carbohydrate intolerance and to adjust the results of neonatal outcomes for selected variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. All p values were two-tailed, and p values of less than 0.05 were considered statistically significant.

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Results

We reviewed the charts of 1432 women, 928 in Hôpital Sainte-Justine, 404 in Hôpital Maisonneuve­Rosemont and 100 in Centre hospitalier de Rouyn-Noranda.

Incidence of carbohydrate intolerance

Among the 1432 women, 358 (25.0%) were classified as "no diagnosis." Table 1 presents the demographic characteristics of the women with no diagnosis and of the women tested. Age, parity, pregravid weight and BMI, as well as the proportion of women with chronic disease, were similar in both groups. Fewer of the women who were tested than those with no diagnosis had a parity of two or more (p < 0.05). More of the women tested than those with no diagnosis were obese (p < 0.01), were white (p < 0.05) or had a family history of diabetes mellitus (p < 0.001).

The incidence of carbohydrate intolerance was calculated on the basis of the 1074 women who were tested (Table 2). Seventy-two women (6.7%) had gestational glucose intolerance, and 98 (9.1%) had gestational diabetes mellitus. Forty-six (27.1%) of the women with carbohydrate intolerance were younger than 30, were not obese and had no family history of diabetes mellitus.

The multiple logistic regression analysis showed that the risk factors associated with carbohydrate intolerance were a family history of diabetes mellitus (p = 0.0001, OR 2.3, 95% CI 1.6 to 3.3), a chronic disease (p = 0.008, OR 1.3, 95% CI 1.3 to 3.3) and age over 24 years (p = 0.013, OR 1.8, 95% CI 1.1 to 3.1).

Characteristics of the women who were treated or not treated

Among the 170 women with carbohydrate intolerance proven by abnormal results of the glucose challenge test and the oral glucose tolerance test, 50 were not treated. The demographic characteristics of the controls, the women who were treated and those who were not treated are reported in Table 3. The age, pregravid weight and BMI were higher among the women who were treated than among the controls (p < 0.05). Fewer of the women who were treated than the controls were younger than 25 years (p < 0.05), and more of the women who were treated than of the controls had a family history of diabetes mellitus (p < 0.01). The demographic characteristics of the women who were not treated did not differ from those of the controls. When compared with the women who were treated, a greater proportion of the women who were not treated were younger than 25 years and primigravid (p < 0.05). The women who were not treated had a lower mean BMI than those who were treated (p < 0.05).

Results of the glucose challenge test and the oral glucose tolerance test are presented in Table 4. The women who were not treated had lower glucose levels on the glucose challenge test and on the fasting oral glucose tolerance test than those who were treated (p < 0.05). In Hôpital Sainte-Justine, but not the other hospitals, the glucose levels at 1 hour on the oral glucose tolerance test were lower among the women who were not treated than among those who were (p < 0.05). The proportion of gestational glucose intolerance was higher among the women who were not treated than among those who were treated (p < 0.001).

The rate of pre-eclampsia was not statistically different among the three groups: it was 2.2% among the controls, 5.0% among the women who were treated and 2.0% among those who were not treated. Insulin therapy was provided to 28 women (23.3%).

Neonatal outcomes

There were three perinatal deaths among the controls but none among the women with carbohydrate intolerance. Data on deliveries and main neonatal outcomes are presented in Table 5. Rates of primary cesarean section, mean gestational age and newborn weight did not differ significantly among the three groups. Induction of labour was statistically more frequent among the women who were treated than among the controls (p < 0.01). Ten newborns (1.1%) born to the controls weighed more than 4500 g, whereas none of those born to the women with carbohydrate intolerance reached this weight. The controls and the women who were treated had similar rates of newborns weighing more than 4000 g and LGA newborns. After correction for maternal age, obesity, parity, ethnic origin and chronic disease, the controls and the women who were treated had similar rates of newborns weighing more than 4000 g (OR 1.1, 95% CI 0.8 to 1.5) and LGA newborns (OR 0.6, 95% CI 0.3 to 1.3). The women who were not treated delivered significantly more newborns weighing more than 4000 g and LGA newborns than the controls and the women who were treated. After correction for maternal age, obesity, parity, ethnic origin and chronic disease, the women who were not treated had higher rates of newborns weighing more than 4000g and LGA newborns than the controls (OR 2.2, 95% CI 1.1 to 4.6 and OR 1.8, 95% CI 1.1 to 4.3, respectively) or than the women who were treated (OR 2.5, 95% CI 1.1 to 7.1 and OR 3.1, 95% CI 1.1 to 9.0, respectively).

The rate of neonatal hypoglycemia among newborns born to the controls and to the women who were treated did not differ significantly, either before or after correction for gestational age (OR 1.1, 95% CI 0.8 to 2.1). Newborn hypoglycemia was significantly more frequent among the newborns of the women who were not treated than among the newborns of the controls and of the women who were treated. After correction for gestational age, newborn hypoglycemia remained statistically higher among the newborns of the women who were not treated than among the newborns of the controls (OR 2.7, 95% CI 1.2 to 4.9) or of the women who were treated (OR 2.9, 95% CI 1.1 to 8.3).

The newborns of the controls and the women who were treated had statistically similar rates of hyperbilirubinemia, before and after correction for gestational age (OR 1.3, 95% CI 0.9 to 1.7). Newborn hyperbilirubinemia was more frequent among the newborns of the women who were not treated than among those of the controls and the women who were treated. After correction for gestational age, the rate of newborn hyperbilirubinemia remained higher among the newborns of the women who were not treated than among the newborns of the controls (OR 1.7, 95% CI 1.1 to 2.6) or of the women who were treated (OR 2.9, 95% CI 1.1 to 6.8).

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Discussion

This study reports the incidence and the impact of carbohydrate intolerance in pregnancy in three institutions in Quebec. These institutions deliver care to different populations and, hence, represent a broad cross-section of patients. Hôpital Sainte-Justine serves the western part of Montreal, Hôpital Maisonneuve­Rosemont, the eastern part of Montreal, and Centre hospitalier de Rouyn-Noranda, the northern part of the province. Given the logistical difficulties, it would be extremely laborious and expensive to conduct this type of study on a provincial or national basis. One would have to study not only the diagnostic sheets for all of the patients but also their charts to ascertain whether the absence of "gestational diabetes mellitus" or "gestational glucose intolerance" on the diagnostic sheet meant that the glucose challenge test or the oral glucose tolerance test had never been performed or that these tests had yielded normal results. However, caution should be used when extrapolating our data to the entire Canadian population, given the variations in ethnic background among Canadians in different regions of the country.

Although this study was retrospective and observational rather than randomized, our observations should not be discounted. Given the ethical issues involved, randomized controlled studies of untreated carbohydrate intolerance, particularly gestational diabetes mellitus, are very difficult to perform.

We have reported the incidence of gestational glucose intolerance as well as gestational diabetes mellitus, since carbohydrate intolerance in pregnancy is a continuum, just as it is when pregnancy is not a factor.[29] The newborns of pregnant women with gestational glucose intolerance are prone to the same neonatal complications as those of women with gestational diabetes mellitus.[26,30-33] Previous studies have shown that the same therapy used to treat gestational diabetes mellitus lowers the rate of neonatal complications of gestational glucose intolerance as well.[34,35]

In our study, we observed a much higher rate of gestational diabetes mellitus (9.1%) than that usually quoted (3%). This rate cannot be due to a higher-than-normal proportion of high-risk women in our study. A broad cross-section of patients was involved, including women followed through private as well as hospital clinics. Furthermore, women referred after 26 weeks of pregnancy were excluded from our study, to eliminate transfers for gestational diabetes mellitus or for other problems associated with the condition. Nor can the high incidence of gestational diabetes mellitus be explained by the use of two different sets of criteria. In the two institutions that used the standard criteria, the incidence rates of gestational diabetes mellitus (7.0% and 8.7%) were still higher than 3.0%. On the other hand, the observed incidence of gestational diabetes mellitus may have been overestimated because more of the women tested than those not tested were obese and had a family history of diabetes mellitus. If we assume that none of the untested women had carbohydrate intolerance, the incidence of gestational diabetes mellitus would decrease to 6.8%. Since this assumption is very unlikely, the true incidence must be between 6.8% and 9.1%, still higher than that usually quoted.

In contrast to previous studies,[20,24,36,37] we did not observe that obesity, parity or ethnic origin were risk factors for carbohydrate intolerance. However, this discrepancy may be explained by the fact that nonobese women were tested less frequently than obese women, that parity was related to maternal age (which was a factor), that the number of black and Asian women in our study was small, and there were no East Indian, Hispanic or native women in our sample. We observed that chronic disease was a risk factor for carbohydrate intolerance. Combining medical disorders such as chronic hypertension, asthma, thyroid disease and inflammatory bowel disease in one category may seem arbitrary. However, we did so because some diseases, such as chronic hypertension, are known to be related to carbohydrate intolerance and because we wanted to identify women who could not be considered healthy.

Our study did not have the statistical power to reach definitive conclusions about the impact of untreated carbohydrate intolerance on perinatal mortality. However, we observed higher rates of LGA newborns, newborns with hypoglycemia and with hyperbilirubinemia among the women who were not treated than among the controls and the women who were treated. The lower rate of neonatal complications among the women who were treated could not be explained by the inclusion of fewer women with chronic diseases in this group. In fact, the women who were treated had more of the usual risk factors for neonatal complications than those not treated: more of them were older than 25 years, and their BMI scores and glucose levels on the fasting oral glucose tolerance test were higher. The increased neonatal morbidity among newborns of the women not treated, compared with those of the women who were treated and of the controls, could not be explained by factors that interacted with carbohydrate intolerance, such as maternal age, obesity, parity, ethnic origin, chronic disease and gestational age. After correction for these variables, the differences in neonatal outcomes remained. Thus, there was no explanation for the high incidence of neonatal complications among the women with untreated carbohydrate intolerance other than the lack of treatment.

Some of these neonatal complications, such as hypoglycemia and hyperbilirubinemia, have short-term implications. However, greater-than-normal neonatal weight has long-term as well as short-term consequences. Cesarean section, a short-term consequence of fetal macrosomia, was no more frequent among the women who were not treated than among the women in the other groups. This may be because the decision to perform a caesarean section is multifactorial. However, macrosomia has also long-term consequences: follow-up studies have shown that newborns with macrosomia are prone to teenage obesity and to abnormal glucose tolerance.[38-40] At the end of the first year of life, the large body size is not longer noticeable. However, accelerated weight gain recurs at 5 to 9 years of life. The impairment of glucose tolerance is greater at 15 to 19 years than at younger ages among these children. Childhood weight and glucose tolerance are also affected by the degree of maternal carbohydrate intolerance during pregnancy.[39]

Our data suggest that carbohydrate intolerance is a common complication of pregnancy and that it has an impact on neonatal outcomes. Our results should therefore serve to highlight the problem of carbohydrate intolerance in pregnancy and to ensure that this problem gets the appropriate attention.

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