Iranian Journal of

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Diabetes during pregnancy is either concurrent diabetes, diagnosed before pregnancy, or ‘gestational diabetes mellitus’ (GDM), first diagnosed in pregnancy. GDM is the commonest metabolic disorder of pregnancy, with a prevalence of one to 14 percent, depending on the reporting team. The prevalence of GDM in Tehran is 4.7%. Diabetes concurrent with pregnancy is diagnosed according to the recently revised criteria of the National Diabetes Data Group (NDDG). GDM is diagnosed with a 100-gram 3-hour glucose tolerance test (3hGTT100), with at least two abnormally high readings being required for a definite diagnosis. Screening for GDM is still a matter of dispute. Universal or selective screening? Each has its supporters. The American Diabetes Association (ADA) recommended universal screening until 1997, and this is still recommended for areas with a high prevalence of GDM. Diabetes during pregnancy has multiple potential consequences for mother and fetus fetal macrosomia being the commonest. The children of diabetic mothers are also more likely to become overweight and develop impaired glucose tolerance. ADA recommendations for glycemic control in diabetic mothers-to-be include maintaining their fasting blood glucose between 60 and 95mg/dl, and their postprandial blood glucose between 80 and 120mg/dl. Measurement of urinary ketones is recommended when the patient is on a calorie-restricted diet. Lifestyle changes are an integral part of management. Insulin requirements and calorie intake must be adjusted in line with weight gain as pregnancy progresses.

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Background: Estimation of cost effectiveness and cost benefit are intrinsic to the design and evaluation of healthcare systems. The aim of most studies of gestational diabetes screening has been to modulate screening parameters to reduce the eligible population and therefore costs. We analysed the findings of a cross-sectional study of gestational diabetes mellitus carried out in Tehran to determine the screening method best suited to the socio-economic profile of our population.
Methods: 2416 pregnant women were universally screened in Tehran teaching hospitals. Each patient’s risk factors and laboratory results were recorded. The 50gGCT was used to screen and the 100gOGTT to confirm a diagnosis of GDM.
Results: Switching from the 130mg/dl to the 140mg/dl threshold, case-detection sensitivity declined by 12% (to 88%), with the per-pregnancy cost dropping from 30,410 to 25,641 Rials (from US$3.80 to 3.20) [-15.6%], and the cost per detected case from 644,488 to 619,500 Rials (from US$80.56 to 77.43) [-3.87%].
Conclusion: We recommend adoption of the universal screening approach in Iran for 4 reasons: (1) The high prevalence of gestational diabetes in the low-risk group (2) The poor level of healthcare provided in Iran compared with societies that have opted for the selective approach (3) The lower cost of screening and diagnostic tests in Iran compared with the aforementioned and (4) The high cost of treating the complications of diabetes.

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Introduction: Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance occurring or detected for the first time during pregnancy. Hypertension occurring as a result of pregnancy is called pregnancy-induced hypertension (PIH), which is itself divided into two groups: gestational hypertension and pre-eclampsia. The aim of this study is to compare the incidence of hypertensive disorders in patients with GDM and controls.
Methods: This is a case-control study of 2416 pregnant women attending 5 antenatal clinics attached to Tehran University of Medical Sciences. The universal two-step screening approach was used: first, all women underwent a 50-gram 1-hour glucose challenge test second, all women with a 1-hour blood glucose concentration higher than 130mg/dl underwent a 100-gram, 3 hour oral glucose tolerance test. Carpenter and Coustan’s criteria were used to diagnose GDM. 220 women with a normal glucose challenge test were chosen as controls. GDM cases and controls were matched for age, body mass index, parity, and gestational age.
Results: 114 women overall were diagnosed with GDM. Mean age, BMI, and parity in GDM and control groups were 29.09±6.13 and 28.64±6.00 years, 27.43±4.33 and 26.64±1.8 kg/m2, and 1.79 and 1.52 births, respectively. Women with GDM had a higher prevalence of essential hypertension, PIH, and pre-eclampsia than matched controls.
Conclusion: Our results show that hypertensive disorders are more common in women with GDM than in normoglycaemic controls of similar age, parity and BMI.

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Background: The American Diabetes Association in 1997 switched its recommendations regarding the screening of pregnant women from universal to risk factor-based screening. The ADA specifically recommended that screening is not cost-beneficial in women under the age of 25, with a normal weight and negative family history of diabetes.
Methods: 910 pregnant women attending the diabetes clinic at Bushehr University of Medical Sciences were screening for gestational diabetes using a 50-gram glucose challenge test. All the women were 24-28 weeks pregnant at the time of testing. Women with a post-load blood glucose of ≥140mg/dl were referred for a 3-hour oral glucose tolerance test. The presence of ADA risk factors was recorded, as was the absence of all three risk factors, and compared with the results of 50-gram GCT. We evaluated the predictive value of different combinations of risk factors relative to the results of screening.
Results: 66 women (6.9%) had a positive screening test, with 16 (1.75%) eventually diagnosed with GDM based on OGTT results. GCT was negative in 616 (95.3%) women, who had at least one of the three risk factors – age >25 years, BMI ≥27kg/m2, or a positive family history of diabetes – and in 231 (27.3%) women who had none of these risk factors [odds ratio = 70.3, 95%-CI = 2.23-22.21 p<0.0001].
Conclusion: Selective screening of pregnant women will detect most cases of gestational diabetes where resources to implement universal screening are limited. The most important factors in selecting screening candidates are age, body mass index, and family history of diabetes mellitus.

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Background: Early detection of carbohydrate intolerance is important to prevent maternal and perinatal complications. This study aims to determine association of symptoms and clinical feature with different degree of carbohydrate intolerance in comparison with healthy pregnant women.
Methods: Two thousand four hundred sixteen pregnant women referred to five university hospital clinics were followed up until delivery. Previously known diabetic patients were excluded from the study. The universal screening was performed with a 50-g 1-hour glucose challenge test (GCT). Those with plasma glucose 130mg/dl underwent a 100-g 3-hour glucose tolerance test (GTT) to diagnose gestational diabetes mellitus (GDM) according to Carpenter and Coustan criteria. Also based on result of GCT and GTT all pregnancy divided to four groups GDM, impaired GCT (IGCT), impaired GTT (IGT) and normal pregnancy. Family and obstetric histories were taken followed by a complete physical examination included: BMI and blood pressure measurements, excess weight gain during pregnancy, proteinuria, glycosuria, polyhydramnios, and edema. Symptoms were considered were as followed: polyuria, polydipsia.
Results: Among the 2416 pregnant women, 114(4.7) were diagnosed with GDM. Of the 114, 42(36.8%) were obese, 39 (34.2%) had glycosuria, 5 (4.3%) had pre-eclampsia, , 22 (19.2%) had abnormal excess weight gain during pregnancy. The most important symptoms were polyuria (14.9%), polydipsia (12.6%). In comparison with healthy group, GDM patients had a significantly higher BMI, glycosuria, polyhydramnios, proteinuria, and excess weight gain. Association of these symptoms in GDM patients was significantly different from that in healthy pregnant women. Out of 114 GDM patients 59 (51.7%) did not have any symptoms or any abnormal clinical features.
Conclusion: The rate of asymptomatic patients in different level of carbohydrat intolerance indicates that symptom – based screening would miss many subjects. Despite clinical feature is not a reliable basis for screening GDM patients, it maybe used to improve maternal surveillance.

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Background: Gestational diabetes mellitus is a common metabolic disorder in pregnancy. Low levels of sex hormone–binding globulin level (SHBG) is associated with increased insulin resistance and hyperinsulinemia. The aim of this study was comparison of SHBG levels between gestational diabetic pregnant women and normal ones.
Methods: Serum SHBG concentration were measured in 38 women with gestational diabetes and in 143 women with normal pregnancy. The levels of Insulin, C-peptide and testosterone were measured and Insulin resistance was estimated via HOMA Index. Insulin sensitivity was estimated via QUIKE Index.
Results: Serum SHBG concentrations was significantly lower in the diabetic group (P=0.015). In a logistic regression model after adjustment of age, body mass index (BMI) and number of gravid, lower than 25 percentile of SHBG was independently effective in prediction of gestational diabetes mellitus.
Conclusion: SHBG concentrations are lower in gestational diabetic pregnant women and low levels account as a predictor of gestational diabetes mellitus.

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Background: Few studies have investigated maternal leptin concentrations in women with pregnancies complicated by gestational diabetes mellitus (GDM), and these published results are conflicting. We examined the association between plasma leptin concentration and GDM risk.
Methods: As a cross-sectional study 741 pregnant women that referred to five university hospital clinics were recruited. The universal screening was performed with a GCT-50g and those with plasma glucose level ≥130mg/dl, were diagnosed as GDM if they had an impaired GTT-100g based on Carpenter and Coustan criteria. The level of insulin was measured during OGTT-100g. Also maternal plasma leptin concentrations were measured.
Results: GDM patients had higher age, parity, BMI, and serum leptin concentration as compare with normal pregnancies. In logistic regression model serum leptin levels were independent factor for GDM.
Conclusion: Serum leptin concentrations can predict GDM.

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Background: Detecting mothers with gestational diabetes mellitus (GDM) is not only important in prevention of prenatal morbidities but also has significant effect on neonatal and maternal long term outcomes. Today, there are screening tests for GDM but they are time-consuming and expensive, therefore it seems necessary to perform testes that are uses expensive but with higher sensitivity and specificity. The aim of this study was to determine a cut - off point of fasting plasma glucose (FPG) for screening of GDM.
Methods: 200 pregnant women referring to the perinatal clinic of Imam Khomeini hospital, (Sari – Iran) were studied. All cases with age ≥25 years old, history of recurrent abortion, GDM, preeclampsia, macrosomia, still birth, diabetes mellitus(DM) in first degree family or pre gestational body mass index ≥25kg/m2 were selected. Those with pre gestational diabetes mellitus were excluded. All of participants underwent a 50 g glucose challenge test (GCT) between the 24th and 28th gestational week. If 1- hour plasma glucose was more than 130 mg/dl, a 3- hour 100g oral glucose tolerance test (OGTT) was performed. The diagnosis of GDM was made by ADA 2006 recommendation (Carpenter and Coustan diagnostic criteria). Referring to the Receiver Operative Characteristic Curve, level of FPG having highest sensitivity and specificity in diagnosis of GDM was determined.
Results: From 200 participants, 65 women had positive GCT, of them 58 (response rate 89%) referred for 100g OGTT and 20(10%) were diagnosed GDM. Using ROC curve and under curve area of 0.853 the FBG level of 91.5 mg/dl, showed the highest sensitivity and specificity, 80% and 92% respectively in diagnosis of GDM.
Conclusion: FBG ≥ 91.5 mg/dl has good sensitivity and specificity in screening of GDM. Since this is simpler and cheaper than 50g GCT, is recommended as a screening method in diagnosis of GDM.

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Background: Pregnancy is a condition that favors oxidative stress mostly because of the mitochondria-rich placenta. Transitional metals, especially Iron, which is particularly abundant in the placenta, are important in the production of free radicals. Also studies showed that free radicals has a role in GDM. This study was performed to compare Iron status between gestational diabetes mellitus (GDM) patients and control groups.
Methods: As a case- control study 34 women with GDM were compared with 34 Healthy women matched for referred center, age, parity and BMI. Iron status measurements including ferritin, serum iron, total iron binding capacity (TIBC), hemoglobin, MCV and MCH at 24-28 weeks of pregnancy were assessed and compared between two groups.
Results: In this study, concentration of serum ferritin, Iron, transferin saturation and hemoglobin, MCV and MCH were significantly higher in GDM group and TIBC was significantly lower in this group as compared with controls (P<0.05). No significant association was observed in other variables including familial history of diabetes and GDM
Conclusion: Our findings indicate an association between increased Iron status and GDM. The role of excess Iron from Iron supplementation in the pathogenesis of GDM needs to be examined.

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Background: Glucose metabolism impairment may occur during some pregnancies especially of advanced age and history of previous gestational diabetes and may result in hazardous consequences both for mother and neonate.

Methods: The present study as a case-control was conducted on 420 referred pregnant women to Shiraz hospitals that involve 70 diabetic patients and 350 non-diabetic women. Data analyzed by analysis of variance and χ square for univariate and logistic regression for multivariate analysis.

Results: From 70 diabetic patients 22(31.4%) afflicted with overt diabetes as well as 48 (68.6%) gestational diabetes. Gestational diabetes history (OR=23.14), hydramnious (OR=13.26), glucosuria at 3^rd trimester (OR=11.49), family history of diabetes (OR=4.09) and age (OR=1.03) were the most important risk factors for gestational diabetes, respectively. History of macrosomia in previous pregnancies (OR=18.83) and history of previous cesarean section (OR=11.96) were the most important predictors for overt diabetes.

Conclusion: In view of several threatening consequences of diabetes during pregnancy, screening for diabetes especially in mothers with gestational diabetes history and family history of diabetes is essential in order to control and prevention of these outcomes in mother and neonate.

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Background: There are no available reports indicating the effects of Dietary Approaches to Stop Hypertension (DASH) eating plan on insulin resistance, inflammation and oxidative stress among pregnant women with gestational diabetes mellitus (GDM) We aimed to investigate the effects of DASH diet on insulin resistance, serum hs-CRP and biomarkers of oxidative stress among pregnant women with GDM. Methods: This randomized controlled clinical trial was performed among 32 pregnant women diagnosed with GDM at 24-28 weeks' gestation. Subjects were randomly assigned to consume either the control (n=16) or DASH diet (n=16) for 4 weeks. The DASH diet was rich in fruits, vegetables, whole grains, and low-fat dairy products and low in saturated fats, total fats, cholesterol, refined grains, and sweets, with a total of 2400 mg/d sodium. The control diet contained 40-55% of its energy as carbohydrates, 10-20% as proteins and 25-30% as total fats. Fasting blood samples were taken at baseline and after 4 weeks of intervention to measure fasting plasma glucose (FPG), serum insulin and hs-CRP, HOMA-IR, plasma total antioxidant capacity (TAC) and total glutathione levels (GSH). Results: Consumption of DASH diet, compared to the control diet, resulted in decreased FPG (-7.62 vs. 3.68 mg/dL P=0.02), serum insulin levels (-2.62 vs. 4.32 µIU/ml, P=0.03) and HOMA-IR score (-0.8 vs. 1.1 P=0.03). Increased concentrations of plasma TAC (45.2 vs. -159.2 mmol/L P<0.0001) and GSH (108.1 vs. -150.9 µmol/L P<0.0001) were also seen in the DASH group compared with control group. We failed to find a significant difference in mean changes of serum hs-CRP levels between the two diets. Within-group comparisons revealed a significant reduction in plasma TAC and GSH levels in the control diet, while a significant rise in these biomarkers in the DASH diet. Conclusion: In summary, consumption of DASH diet in pregnant women with GDM had beneficial effects on FPG, serum insulin levels, HOMA-IR score, plasma TAC and total GSH levels. The effects of this dietary pattern on pregnancy outcomes need to be investigated in future studies.

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Background: This study was designed to assess the effects of calcium and vitamin D supplementation on the metabolic status of pregnant women with gestational diabetes mellitus (GDM).

Methods: This randomized placebo-controlled trial was performed at maternity clinics affiliated to Kashan University of Medical Sciences, Kashan, Iran. Participants were 56 women with GDM at 24–28 weeks gestation (18 to 40 years of age). Subjects were randomly assigned to receive calcium plus vitamin D supplements or placebo. All study participants were blinded to group assignment. Individuals in the calcium–vita- min D group (n = 28) received 1,000 mg calcium per day and a 50,000 U vitamin D3  pearl twice during the study (at study baseline and on day 21 of the intervention), and those in the placebo group (n = 28) received two placebos at the mentioned times. Fasting blood samples were taken at study baseline and after 6 weeks of intervention.

Results: The study was completed by 51 participants (calcium–vitamin D n = 25, placebo n =26). However, as the analysis was based on an intention-to-treat approach, all 56 women with GDM (28 in each group) were included in the final analysis. After the administration of calcium plus vitamin D supplements, we observed a significant reduction in fasting plasma glucose (p < 0.001), serum insulin levels (p = 0.02) and HOMA-IR (p = 0.001) and a significant increase in QUICKI (p = 0.003) compared with placebo. In addition, a significant reduction in serum LDL-cholesterol (P=0.02) and total cholesterol: HDL-cholesterol ratio (p = 0.003) and a significant elevation in HDL-cholesterol levels (p = 0.01) was seen after intervention in the calcium–vitamin D group compared with placebo. In addition, calcium plus vitamin D supplementation resulted in a significant increase in GSH (p =0.03) and prevented a rise in MDA levels (p = 0.03) compared with placebo.

Conclusion: Calcium plus vitamin D supplementation in women with GDM had beneficial effects on their metabolic profile.

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Background: Gestational diabetes in on of common complications of pregnancy which has different complications for fetus and mother. Aim of present study was to review the effect of six weeks aqua training in second trimester of pregnancy on visfatin and glucose tolerance of gestational diabetic women.
Methods: In this semi experimental research 24 gestational diabetic mothers who recourse to hafez clinic of shiraz city which were in 23- 24 week of pregnancy select as sample and divided in two groups of 12 persons of aqua training and control. Aqua training group trained aqua trainings 6 weeks, 3 sessions per week and 45 minutes per session. In this period of the time control group has just their daily activities. For measure the research variables fasting blood sample gathered from antecubital vein in pretest and post test.
Results: Six weeks aqua training in second trimester of pregnancy has significant effect on increase of visfatin and decrease of glucose tolerance of gestational diabetic women (p=0.001).
Conclusion: It seems that for improvement of visfatin levels and glucose tolerance of gestational diabetic women can use six weeks aqua training in second trimester of pregnancy.
 

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Background: Insulin is first choice for gestational diabetes control, but its needed to frequent injections; one thing that is difficult for pregnant women, so interest to metformin consumption is increased. Metformin easily crosses the placenta and its fetal blood levels is equivalent to the level of the mother's blood. Metformin also easily cross the brain barrier and enter the brain. Possible side effects of metformin compared to insulin on fetus brain development was concerned to design of present study.  

Methods: In this cross-sectional prospective trial, gestational diabetes women were recruited randomly to insulin (64 patients) and metformin (64 patients) groups and compared for pregnancy and neonatal outcome and also six-month-old infancy developmental indexes. The results considered significant if P value was ≤ 0.05.
Results: Six-month body mass index of insulin group women was significantly more than metformin group(P=0.05), but there was not any significant difference in cesarean section, preterm labor, dystocia, preeclampsia and still birth rate between two groups. Also neonatal characteristics, need to admission and six-month-old infancy developmental indexes according to Ages stages questionnaire were no different between two groups.
Conclusion: Metformin consumption in compare to insulin was not associated with maternal, neonatal and six-month-old infancy developmental indexes side effects.

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Background: Gestational diabetes is one of the most common metabolic disorders during pregnancy. The purpose of this study was to determine Prevalence of Gestational Diabetes Mellitus in Pregnant Women Referred to Therapeutic and Health Centers in Hamadan Town.
Methods: This descriptive-sectional study was done in the year2014 on 620 pregnant women Referred to The health Centers in Hamadan Town. The necessary information was collected by means of a self-made
Questionnaire. The scientific validity of the questionnaire Comments 15 members of the faculty of nursing and midwifery. The necessary amendments were made. To determine the reliability question a pilot study on 10 patients was performed twice with an interval of 10 days and offer 0/91 reliability was confirmed Then the data was analyzed by using SPSS software, independent Fisher test, Chi-square and a=0.05 was taken as the significant level.
Results: 110 of the 620 cases studied (almost 17.1%) suffered from gestational diabetes mellitus and 38 cases of all (almost 6.1%) had overt diabetes. Mean age of the pregnant women was30.6±5 and BMI25.3±4.1 their mean number of pergment was 1.6±0.8. Increasing the hours of mother's work at home, body mass index, household size, number and history of abortion, number of pregnancies and delivery, and the history of diabetes in the family, the chance of having diabetes also significantly increases (P<0.05).
Conclusion: Regarding the great importance of gestational diabetes and its complications on the fetus, diabetes preventive practices demand special attention to pregnant women Regarding the trend of increasing the incidence of pregnant women to gestational diabetes mellitus and the effect of demographic and obstetric factors on its development, screening for women before admission for diabetes and healthy lifestyle education is recommended.

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Background: Although a positive association between type 2 diabetes and breast cancer has been reported, an association with gestational diabetes mellitus (GDM) is less clear. This study aimed to assess the relationship between the history of GDM and the incidence of BC a long term population based study.
Methods: To conduct this research, 4076 women aged 20-50 years who participated in the first phase of Tehran-Lipid-and-Glucose-Study, who had at-least one pregnancy were included. Each participants were asked about the history of GDM every 3 years. They was evaluated about the occurrence of breast cancer (BC). Cox-survival analysis was used to measure the Hazard-ratio (HR) for both groups with and without history of GDM
Results: The study population included 886 women with prior GDM and 3,909 women without history of GDM. The median duration of follow-up among women with and without the history of GDM were 12.12 and 11.62 years, respectively. The incidence of BC was 0.64 per 1,000 year-olds with confidence=interval of 95% (0.44-0.91). Among them, 4 cases were reported in women with GDM and 26 cases in women without GDM. (Incidence of 0.36 per 1000 person-years with confidence=interval 95% (0.11-0.99) in women with prior GDM and 0.73 per 1,000 person-years with confidence=interval 95% (0.49-1.1) in women without a history of GDM.
Conclusion: Our study showed that the history of GDM is not an independent risk factor for breast cancer.

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Background: The Actinobacteria and Bifidobacterium population, which are the beneficial intestinal bacteria, was compared between pregnant women with gestational diabetes (GDM) and healthy-one, and their relationship with the amount of dietary macronutrients was investigated.
Methods: Fifty pregnant women with GDM, who were identified in the 24-28 weeks of pregnancy, based on the oral glucose tolerance test, and 50 healthy pregnant women with normal results were selected. Stool samples were collected. Bacterial DNA was extracted and 16S rRNA gene amplification was done by qPCR method, using universal bacterial primers. Food information was collected using a food frequency questionnaire.
Results: In total, Actinobacteria phyla (p=0.02) and Bifidobacterium (p=0.001) significantly lower in the pregnant women with GDM than the normoglycemic. Adjusting to the all factors and grouping, age (p=0.02), and education (p=0.04) showed a significant effect on the gut Actinobacteria population. Higher daily calorie intake decreased the intestinal Actinobacteria population by 11.1 times (p=0.01). Dietary carbohydrate and fat showed a positive effect on the gut Actinobacteria (p=0.02 and p=0.003, respectively). Dietary cholesterol showed a negative effect on the Bifidobacterium population (OR= -0.54, p=0.02).
Conclusion: Increase in dietary carbohydrates and fat with an emphasis on mono- and poly-unsaturated fatty acids, decrease in daily calorie intake and cholesterol lead to increase in the Actinobacteria and Bifidobacterium, as the beneficial gut bacteria.

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Introduction: gestational diabetes is one of the most common diseases during pregnancy, and health literacy of pregnant mothers plays an important role in the prevention and management of the disease. The study aimed to examine and compare the health literacy of pregnant women with gestational and non-diabetic diabetes visiting health centers in the city of Yazd in 1402.
Methods: This descriptive-analytical study was conducted on 206 diabetic and non-diabetic pregnant women, the cluster health center sampling method and pregnant mothers were randomized sampling method. The data was collected using a health literacy questionnaire and analyzed using kayscore tests, Independent t-Tests and variance analysis.
Results: the mean health literacy score of non-diabetic pregnant mothers (74/26±13/75) was significantly higher compared to diabetic mothers (47/27±21/06) (p< 0/05). And 67% of diabetic women had insufficient health literacy. The study also found a strong link between health literacy and maternal diabetes. And diabetic mothers showed an inverse relationship between health literacy and the number of pregnancies and offspring, a trend not observed in non-diabetic mothers.
Conclusion: higher health literacy can help promote diabetes prevention behaviors during pregnancy. Pregnant mothers with higher health literacy levels are likely to make the best decisions about their health and that of their fetus. Which is an indication of the importance of proper health awareness and education for pregnant women.