Introduction

It is estimated that by the year 2030 more than 360 million people will have diabetes
mellitus (DM) and as the burden of the disease increases the management of pregnancies
complicated by DM will be part of the daily obstetric practice in many regions of the world.
Studies investigating the influence of ethnicity on the outcome of pregnancies complicated
by pre-existing diabetes mellitus (PDM) reported variation in the outcome with different
ethnic groups with worse outcome for Asian and Afro-Caribbean mothers compared to
Caucasian , however this difference might be explained by access to and utilization of
preconception and prenatal care .

The physiological changes of pregnancy put the human body in a state of carbohydrate
intolerance. The pregnancy specific hormones, such as human placental lactogen and the
increased levels of cortisol and prolactin, increase the resistance to insulin and call for
more production of the hormone to maintain homeostasis of blood glucose during
pregnancy [4]. Such demand is not met in pregnant diabetic women due to the pathology
associated with diabetes

Numerous studies examining cohorts born mostly in the first half of the 20
th
century have
emphasized the inverse relation between low birth weight and incidence later in life of
cardiovascular and metabolic conditions, such as hypertension and type 2 diabetes.
Epidemiologic studies seldom consider the effects of preterm birth and intrauterine growth
restriction separately when studying the relation of these factors to low birth weight.
Studies have suggested that adolescents and young adults born preterm have higher
incidence of risk factors for metabolic (insulin resistance) and cardiovascular (higher blood
pressure) dysfunctions. With the increased survival of preterm newborns over the past 30
years, a substantially greater proportion of young adults are born before 37 or even 32
weeks gestation and thus may represent a growing population at risk for conditions
related to metabolic syndrome as they get older.

Pregnancy can be considered a stress test for future cardiovascular and metabolic health.
Women with a history of gestational diabetes, gestational hypertension or preeclampsia
are at increased risk of metabolic syndrome later in life. Furthermore, studies have shown
that women born with low birth weights are at increased risk of gestational hypertension,
preeclampsia and gestational diabetes. However, many of these studies either have not
taken into account gestational age or have a number of shortcomings, such as small sample,
young population (mostly teenagers), degree of prematurity not specified or study
population consisting mostly of late preterm births.


Cardiovascular disease (CVD) is the leading cause of death in women, accounting for a
Quarter of deaths in both high income and low and middle income settings. It is
increasingly recognized that women experiencing common pregnancy related
complications: gestational diabetes (GDM), preeclampsia, intra-uterine-growth retardation
and preterm delivery are at increased risk of future CVD. Therefore, it has been suggested
that pregnancy offers an opportunity to identify women at-risk of future CVD. But whether
these pregnancy complications have separate, independent affects on future cardiovascular
risk, and if so, how their relative and absolute associations differ from each other remains
unclear. Such information is important for exploring whether there are common
underlying pathways between these conditions and future cardiovascular risk and for
considering the most efficient methods for using pregnancy complications to target
preventive initiatives in women.

Literature review

A study about the associations of pregnancy diabetes, hypertensive disorders of
pregnancy (HDP), preterm delivery and size for gestational age with calculated 10 year
CVD risk (based on the Framingham score) and a wide range of cardiovascular risk factors
measured 18 years after pregnancy (mean age at outcome assessment: 48 years) in a
prospective cohort of 3,416 women. Gestational diabetes (GDM) was positively associated
with fasting glucose and insulin, even after adjusting for potential confounders whilst HDP
were associated with BMI, waist circumference, blood pressure, lipids and insulin. Large for
gestational age (LGA) was associated with greater waist circumference and glucose
concentrations, whilst small for gestational age (SGA) and preterm delivery were
associated with higher blood pressure. The association with the calculated 10 year CVD
risk based on the Framingham prediction score was OR=1.31 (95%CI: 1.11, 1.53) for
preeclampsia and 1.26 (0.95, 1.68) for GDM compared to women without preeclampsia and
GDM respectively. Abigail Fraser, MPH, PhD1, Associations of Pregnancy Complications with Calculated
CVD Risk and Cardiovascular Risk Factors in Middle Age: The Avon Longitudinal Study of Parents and Children,
2012.

A retrospective cohort study for women who delivered in King Khalid University Hospital
(KKUH) during the period of January 1st to the 31st of December 2008. The pregnancy
outcomes of the women with PDM were compared to the outcomes of all non-diabetic
women who delivered during the same study period. Results: A total of 3157 deliveries met
the inclusion criteria. Out of the study population 116 (3.7%) women had PDM. There were
66 (57%) women with type 1 diabetes mellitus (T1DM) and 50 (43%) women with type 2
diabetes mellitus (T2DM). Compared to non-diabetic women those with PDM were
significantly older, of higher parity, and they had more previous miscarriages. Women with
PDM were more likely to be delivered by emergency cesarean section (C/S), OR 2.67, 95%
confidence intervals (CI) (1.63-4.32), P < 0.001, or elective C/S, OR 6.73, 95% CI (3.99-
11.31), P < 0.001. The neonates of the mothers with PDM were significantly heavier, P <
0.001; and more frequently macrocosmic; OR 3.97, 95% CI (2.03-7.65), P = 0.002. They
more frequently have APGAR scores <7 in 5 minutes, OR 2.61, 95% CI (0.89-7.05), P 0.057
and more likely to be delivered at <37 gestation weeks, OR 2.24, 95% CI (1.37- 3.67), P
0.003. The stillbirth rate was 2.6 times more among the women with PDM; however the
difference did not reach statistical significance, P 0.084. Hayfaa A Wahabi1*,Pre-existing
diabetes mellitus and adverse pregnancy outcomes , 2012, retrospective cohort.