Intensive Diabetes Management May Improve Pregnancy : Outcomes in Chinese gravidas with impaired glucose tolerance

In a study of diabetes in pregnancy in Tianjin, China (1,2), gravidas with impaired glucose tolerance (IGT) were found to have poor pregnancy outcomes (3). We studied the effect of an intensive diabetes management plan (IDMP) on pregnancy outcomes in 150 gravidas who developed IGT during pregnancy.

Women were randomized to receive either intensive care (IC; n = 95) or usual obstetric care (UC; n = 55). Of the 95 women randomized to the IC group, 48 (50%) completed the IDMP. All 55 women of the UC group completed the study. Comparisons of pregnancy outcomes were performed by intention to treat. The IDMP consisted of diet and exercise advice, self–home blood glucose monitoring, and/or insulin treatment if indicated, as well as a fortnightly clinical review of glycemic status and other intervention goals. Low intake of calories was prescribed according to pregravid BMI (4), with subjects consuming six evenly spaced meals per day. The goal of the IDMP was fasting capillary whole blood glucose <5.5 mmol/l and a 1.5-h postprandial glucose <7.0 mmol/l. Glucose tests were carried out 1.5 h postprandial. Fasting glucose tests were also performed when the fasting glucose level at the diagnostic OGTT was elevated.

The IC and UC groups were comparable in age, pregravid BMI, weight gain during pregnancy, gestational age at delivery, and fasting and 2-h OGTT glucose levels. The rate of premature rupture of membranes (P-ROM) was significantly lower in the IC group than in the UC group (4.21% [4/95] vs. 20% [11/55], P = 0.0034). The reduced risk for P-ROM in the IC group persisted after controlling for age, stature, pregravid body weight, fasting and 2-h OGTT glucose levels, gestational weeks at the OGTT, caesarean delivery status, and hospital levels (secondary versus tertiary) (odds ratio [OR] 0.135 [95% CI 0.032–0.559]). The frequency of caesarean delivery was also significantly lower in the IC group than in the UC group (64.2% [61/95] vs. 80.0% [44/55], P = 0.0445); the reduced risk was marginally significant after controlling for covariates (0.479 [0.211–1.084]).

Differences in preterm birth, birth weight, perinatal morbidity and mortality, and deformations between the two groups were not statistically significant. No birth trauma or shoulder dystocia occurred in either group. Before the current study, gravidas in Tianjin were not screened for diabetes in pregnancy and IGT was not treated.

This study investigated the effect of an established IDMP on pregnancy outcomes in order to provide evidence for (or indicate the lack of) public health planning toward improved population obstetric care in Tianjin, China. Notwithstanding the inherent limitations in introducing the intensive diabetes management and a small sample size, the current study shows that intensive diabetes management can result in statistically detectable and clinically important improvements in pregnancy outcomes. The challenge for developing countries, such as China, who faces the rising prevalence of type 2 diabetes (5), is to develop evidence-based health services that integrate a traditional beliefs system and century-old practice and that consider economic rationale and, most importantly, the health of women and their children.