Management of GDM and Trans-Generational Prevention Vol.12 (2), December 2021
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R A D S J . B i o l . R e s . A p p l . S c i . 146
Op e n Ac c e s s
F u l l L e n g t h A r t i c l e
Management of Gestational Diabetes mellitus with Risk
Factors and Trans-Generational Prevention
Sabiha Gul1, Kiran Rafiq2,*, Shagufta Nesar3, Syed Waleed Ahmed Bokhari1, Muhammad Azhar Mughal4,
Hafiza Tania Naveel5, Muhammad Idrees1
1Department of Pharmacology, Faculty of Pharmacy, Hamdard University, Karachi, Pakistan.
2Department of Pharmaceutical Chemistry, Institute of Pharmaceutical Sciences, Jinnah Sindh Medical University, Karachi, Pakistan.
3Jinnah College of Pharmacy, Sohail University, Karachi, Pakistan.
4Department of Pharmacology & Therapeutics, Jinnah Sindh Medical University, Karachi, Pakistan.
5Department of Pharmacology, Faculty of Pharmacy, Jinnah University for Women, Karachi, Pakistan.
A B S T R A C T
Background: Gestational Diabetes mellitus (GDM) has become a pervasive health issue of today’s era, leading to be a complicated
disorder globally. It has also been proved to be highly accountable for causing an undesired impact on maternal health of patient as
well as progeny. The high number of reported cases with consequent complications need appropriate medical care and timely attention.
Objectives: The present study was intended to display the real figure of a high rise in GDM in Pakistan, with all involved parameters,
to rectify the real factors either socioeconomic or domestic, accountable for the jeopardizing of disease.
Methodology: The study was conducted in different maternity hospitals of Karachi, Pakistan. Association between GDM with age,
family history, co-morbid complications, fetal complications and others were analyzed by Pearson chi-square test using SPSS.
Results: More than 50% of participants belong to the age bracket of 31-45 years and 31.2% having a positive family history of diabetes.
No known risk factor regarding GDM was present in 40.6% of women. GDM was observed prevalent and associated with poor health
management of mother, and found to increase with elderly mothers (i.e. age of mother at the time of conception) in Pakistan.
Conclusion: GDM should be considered as primary health care for the trans-generational prevention of diabetes and needs to be
addressed as a public health issue in order to cure the mother and fetus during pregnancy and to prevent long term effects of this
disease.
Keywords
Fetal complication, Gestational,
Hyperlipidemia, Insulin Resistant,
Overweight, GDM.
*Address of Correspondence
kiranrafiq@hotmail.com
Article info.
Received: January 14, 2021
Accepted: July 04, 2021
Cite this article Gul S, Rafiq K, Nesar S, Bokhari SWAB, Mughal MA, Naveel HT, Idrees M.
Management of Gestational Diabetes Mellitus with Risk Factors and Trans-Generational
Prevention. RADS J Biol Res Appl Sci. 2021; 12(2):146-153.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium provided the original work is properly cited.
I N T R O D U C T I O N
Pregnancy and parenthood are the state of emotional well-
being and account for satisfaction and sense of worth. The
creation of new life gives courage and happiness to the
marital relations, however, during all the period of
pregnancy mother is on the front line during all the state of
creation1, 2. As a matter of fact, from the beginning of
conception till birth and even after birth, a mother faces
numerous experiences regarding health, socio-economic
burdens, family pressures, health issues etc3. Pregnancy
is a cluster of physical and psychological alterations, and
O R I G I N A L A R T I C L E
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R A D S J . B i o l . R e s . A p p l . S c i . 147
interestingly both may affect the health of fetus and mother
in either positive or negative manner4. According to a
research, approximately 20% women face mood swings
and anxiety disorders, while those having history of
psychiatric illness are even more susceptible for such
conditions that cannot be treated by any psychotropic
medicine, since as FDA has not approved any such
therapy during pregnancy. The handling of pregnancy is a
highly sensitive matter therefore, because of having
teratogenic effects, neonatal toxicity, and risk of long-term
neurobehavioral consequences, the medicines are
carefully prescribed during pregnancy5, 6.
Besides all the possible complications during
pregnancy, gestational diabetes itself is a complex matter7
that is highly accountable for making the pregnancy
handling more difficult for mothers8, 9. Simply, diabetes has
been found to be highly associated with stress and
depression with a fact that this anxiety disorder is also
accompanied with the pregnancy either early or late.
Hence, various factors like social, economic and health
related factors enhance the level of stress that may in turn
be responsible for the onset of hyperglycemic state during
the gestational period. The disorder is thus the state
of glucose intolerance10.
According to the data, the prevalence of hyperglycemia
associated with pregnancy is found one in six globally, and
among that 84% are GDM. The prevalence frequency of
GDM is high among Asian women than white women as in
Asia, the prevalence of GDM is increasing over years11, 12.
The GDM has been found with the progression of Type II
diabetes in the future. However, due to GDM, a transitory
condition is induced by the metabolic stress of pregnancy
which causes carbohydrate intolerance, and can be treated
by diet control and by insulin therapy during the period of
pregnancy. But the condition may or may not be
complicated if it persists after childbirth. This abnormality in
glucose metabolism may or may not be normalized after
delivery, for a reason that there are 40% chances of
gestational diabetics to develop into Non-Insulin-
Dependent Diabetes mellitus (NIDDM) within fifteen years
after childbirth13, 14.
The physiological changes during pregnancy correlate the
future programming about the metabolism and health in
upcoming life, hence childbearing is believed as a window
of maternal health in upcoming life. Adequate health care
guidance and complete nutrition develop an intrauterine
environment that creates an impact on the growth of the
baby, and for this purpose, women during pregnancy
require medical care and guidance. However, in spite of all
significant and essential cure, there is one unavoidable and
unpredictable physiological change that happens during
pregnancy i.e. hyperglycemia, referred to as Gestational
Diabetes mellitus (GDM) or glucose intolerance. This may
also occur due to hormonal imbalances, dysfunctioning of
pancreatic β-cells responsible for releasing insulin, and
distressing insulin sensitivity which normally works as an
anabolic hormone, thus enhances glucose uptake by
peripheral tissues and maintain glucose equilibrium by
controlling the production of glucose from the liver, while
antagonizing the adipose tissue to release lipids15-17.
Insulin resistance is the defined cause of GDM, as a state
of decline in insulin concentrations, however, placental
hormones trigger the insulin resistance to assure receiving
sufficient nutrients by the fetus for vigorous growth. In such
situation, the β-cells release more insulin to normalize the
maternal blood glucose levels and to maintain glucose
homeostasis. Despite insulin resistance, the maternal β-
cells create a balance by increasing insulin synthesis and
secretion, leading to maternal hyperglycemia18-22.
GDM is in compliance with various genetic and
environmental factors, as family history has a significant
impact on the occurrence of diabetes, and as a high-
risk factor for the development of GDM23-25.
Moreover, variations of DNA for diabetes in gene
polymorphisms is also responsible for transgenerational
inheritance of obesity and glucose intolerance in the
offspring from both mother and father. However, the types
of genetic variation contribute to genotypic and phenotypic
characteristics differently in different ethnicities such
as Asian women have the highest GDM rate26-28. This
associated fact also identify the accountability of climate
conditions for GDM, for e.g.: the extremity of weather and
cold to hot temperature situations influence the physiologic
mechanisms, hormonal balance, fats and lipid regulation,
therefore the higher prevalence of GDM has been
observed at high temperature regions29-32. Along with
regional and climate factors33-35 different socio-economic
status, awareness about the disorder, and health care
measures significantly distress the occurrence of GDM in
a direct or indirect manner, which if not addressed, results
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R A D S J . B i o l . R e s . A p p l . S c i . 148
in adverse maternal and neonatal outcomes that will
increase drastically. This demands an early antenatal
screening irrespective of the presence of risk factors for
GDM and thus, it can be controlled by further promoting
awareness of GDM and other pregnancy complications
through educational sessions with dietician,
diabitician or healthcare provider in order to prevent
maternal and fetal complications.
M A T E R I A L A N D M E T H O D S
Study Design and Study Period:
This cross-sectional observational study was conducted in
different maternity/tertiary care hospitals and clinics of
Karachi, Pakistan from October-December, 2020. All the
participants were recruited from primary health care clinics
and hospitals.
Study Population and Sample Size:
Sample size calculations were performed using Open Epi
software to determine the size of sample with 95%
confidence interval. Total 1000 pregnant women of fertile
age (16-45 years old) were selected for this study.
Exclusion Criteria for Study Population:
Women pre-diagnosed with Type 1 diabetes were
excluded from the study.
Study Tool
For the purpose of current study, a questionnaire was
designed according the standard DIPSI (Diabetes in
Pregnancy Study Group India) criteria33 that was designed
under the guidelines of World Health Organization (WHO)
and International Association of Diabetes and Pregnancy
Study Groups (IADPSG) criteria for the diagnosis of GDM.
Accordingly, the study covered following aspects to
analyze the frequency of diabetes among the pregnant
women in Pakistan along with the associated factors.
The survey questionnaire comprises important objectives
including:
1. Socio-demographic details (four items)
2. Risk factors for GDM
3. Fetal complication associated with GDM
4. Disorder association with GDM
5. Treatment choice for GDM
Statistical Analysis:
Data were analyzed using SPSS-20 and the results were
expressed in the form of frequency and percentages. The
association of GDM with different parameters was
analyzed by Pearson Chi-square test. The prevalence of
GDM was compared in different groups made with respect
to age, ethnicity, trimester, family history, co-morbid
disease, maternal complications and fetal complications.
R E S U L T S
The present study was designed and proceeded through a
survey based questionnaire according to the DIPSI criteria
to analyze the frequency and related factors for gestational
diabetes among Pakistani women33. According to the
information obtained from Pakistan Fertility and Family
Planning Survey (PFFPS) for analyzing the health issues
of women during pregnancy, the majority of women faced
diabetes during pregnancy, and in recent years, a high
jeopardy has been observed. According to the reported
data, the different big cities of Pakistan like Karachi,
Peshawar, and Lahore have GDM cases ranging from 8%
to 26% and interestingly, no regular data was reported from
rural areas, that indicates the negligence about this
disorder.
During the analysis, different aspects influencing the GDM
were included like age of mother matters for GDM.
Similarly, a significant correlation was recorded between
age of pregnant woman and GDM. Moreover, in women
with age bracket of 16-30 years, 45.2% population had
diabetes while, in women with age group from 31-45 years,
54.8% were observed having diabetes during pregnancy.
The outcome revealed that the women of older age has
more chances to suffer with GDM according the significant
estimated p-value.
As per weeks of gestation, 8.2% patients were in first
trimester, 38.9% patients were in second trimester and
52.9% patients were in third trimester, with increased
incidence noted in third trimester (Table 1). The data
showed that maternal age is a traditional risk factor for
Gestational Diabetes mellitus (GDM), as according the
American Diabetes Association the lowest cut off is 25
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R A D S J . B i o l . R e s . A p p l . S c i . 149
years, however no such harmony of the age is stated
above which there is significantly high risk of GDM.
Regarding ethnicity in the GDM group, 12.0% participants
were Punjabi, 7.9% Pukhtoon, 13.8% Balochi, 6.9% Sindhi
speaking and 59.5% participants were Mohajir. As ethnicity
relates different demographic facts, cultural background,
and socioeconomic differences and consequently affects
the behavior and approach towards health and education,
and sometimes gender discrimination is observed in some
races. All this may also lead to cause unhealthy pregnancy
with certain complications.
The family history also found to matter as more cases were
of patients who had diabetes, likewise heart diseases and
thyroid were also reported with GDM. However, 40%
population were reported with no family history but
developed GDM. Complicated cases having diabetes and
thyroid along with heart problems were observed in 8%
pregnant women. According to the study, the most
accountable factor for GDM was family history.
Furthermore, pregnancy is complicated due to GDM in a
variety of manner as like most of the infants of GDM
mothers were overweight as compared to the non-GDM
mothers (Table 2).
Table1. Socio-Demographic Data of Women having GDM.
Socio-Demographic
Characteristics
Age in Years
Gestational Diabetes
mellitus (GDM)
(n)
Gestational Diabetes
mellitus (GDM)
(%)
p-value
Age group of Women
16-30 452 45.2%
0.000
31-45 548 54.8%
Ethnicity Punjabi 120 12.0%
>0.05
Pukhtoon 78 7.8%
Balochi 138 13.8%
Sindhi 69 6.9%
Mohajir 595 59.5%
Trimesters First 61 6.1% >0.05
Second 339 33.9%
<0.0001
Third 600 60.0%
Table 2. GDM and Associated Fetal / Maternal Complications.
Pregnancy-Related Fetal, and Maternal
Complications
Pearson Chi Square Value Asymptotic Significance
Family history of pregnant women
1.777 0.000
Diabetes
Heart Disease
Diabetes + Thyroid + Heart Disease
Thyroid Disease
No risk factor
Fetal complication
17.283 0.000
Large Size (more than 9 pound)
Pre-term labor
No complications
Pre mature birth
Small size
Down syndrome
Contd…
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R A D S J . B i o l . R e s . A p p l . S c i . 150
Maternal complications (Comorbidity)
2.336 0.000
Obesity
Hypertension + Obesity
Abnormal blood lipids
Liver disease
Kidney disease
Hypertension
Depression
Thyroid disease
No disease
Treatment Choice for GDM
1.000 0.000
Insulin
Metformin
Diet controlled only
Exercise
Glyburide
D I S C U S S I O N
Pregnancy, a distinctive normal physiological condition, is
a feeling of completion and happiness and a new life is
created. However, normally during pregnancy the body
passes through various changes including both
physiological and psychological, and most of them
normalize after delivery whereas, some account to induce
long lasting effects throughout the life as like diabetes. As
during the period of pregnancy, fetus development is
completely reliant on mother, and to keep the growth of
fetus and mother healthy, there are certain pregnancy
induced metabolic changes considered as normal. But
sometime these disturbances may lead to some
pathological conditions like impaired glucose tolerance,
leading to GDM34, 35.
With the progression of gestation, fasting glucose drops off
gradually with advancing gestation however, the
mechanism is not well defined. But there are some
accountable factors like increased plasma volume in the
beginning of gestation, high feto-placental glucose
utilization, and uptake of carbohydrates (glucose) by
mother in second and third trimester. Interestingly, more
production of hepatic glucose regardless of a decline in
fasting glucose in GDM leads to a simultaneous increase
in fasting insulin and decrease in fasting glucose and this
may aggravate with prolonged fasting36. The hepatic
disturbance causes increased glucose concentrations in
blood despite high insulin concentrations, and that sustains
discrepancy between tissue insulin demands for glucose
monitoring and the ability of the pancreatic β-cells to
produce the required insulin accordingly.
The increasing frequency of Diabetes mellitus among
pregnant women needs the development of preventive
strategies. Different socio-economic factors like cast,
region, diet intake, stress affects the prevalence of this
disorder.
Therefore, the present study was designed to identify and
focus on the facts and figures with associated features of
GDM among Pakistani women. Unfortunately, the disorder
is unnoticed in Pakistan due to unavailability of appropriate
data and uncertain data collection, as the major part of
population lives in rural areas. Hence, cases form
underprivileged areas are not reported or treated, and most
pregnancies and deliveries are handled by inexperienced
or non-institutional and uncertified experienced
obstetricians at home or at local unregistered clinics and
small hospitals settings, devoid of basic emergency
facilities. Further, lack of facilities for antenatal care and
childbirth, and unwanted pregnancies in married women
are more accountable in developing complications during
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R A D S J . B i o l . R e s . A p p l . S c i . 151
pregnancy, leading to different disorders37. The reality
states that the awareness and information related to
reproductive health including infertility, abortions, and
pregnancy handling is inadequate.
In current study, Gestational Diabetes mellitus risk is
higher in women with age group of 31-45 years, as
compared to the women aged between 16-30 years, with a
highly significant p-value. The high risk of GDM in old age
is due to the fall in pancreatic beta cells performance with
age, while in elderly age, the inadequate pancreatic beta
cell response to stimulation develops more insulin
resistance as compared to younger age.
One of the strong factor of GDM is family history. Statistical
analysis showed highly significant ratio between family
history and GDM. Different socio-economic aspects like
joint family system, load of responsibilities, and week
physical health are most common in Indo-Pak that hinders
to live healthy and happy life, and these are the important
reasons of antenatal disorders. Consequently, medicines
are required to be prescribed to manage the glycemic level
in pregnancy and to avoid possible unhealthy effects on
both baby and mother before and after delivery38. The
current study revealed that GDM is managed through diet
control, exercise, insulin and medicine including metformin
and glyburid, however the insulin therapy was found to be
adopted by majority of the population whereas, second
option was by medicine at high frequency and metformin
was established at higher rate for treatment. Management
of GDM through diet control was observed relatively at low
level may be due to the ground reality of pregnancy
cravings, for fulfilling the nutritional need of the woman and
fetus; a principal biological reality. The exercise and work-
out like aerobics, yoga, and walk are considered as a best
remedy for curing or controlling the diabetes and
cholesterol, and also help to reduce stress and depression
normally, and in pregnancy significantly. But unfortunately
the adaptation of this safe management was observed at
very low level as gestating is a lengthy, tiring, and
uncomfortable situation and sometime this laborious work
induces laziness that does not allow the physical activity
and women are more prone to rest39. The obesity in
pregnancy are inter-related with GDM and according to
Royal College of Obstetricians and Gynecologists (RCOG)
moderate exercise like yoga and walk for 30-60min three
times a week is safe during pregnancy with GDM, and it
also significantly reduces the occurrence of GDM and
gestational obesity, along with associated hypertension
and preeclampsia40.
The present study was also focused on the other health
conditions and disorders already present and account for
aggravating the hyperglycemia leading to the GDM. The
obtained data revealed that obesity is a prominent cause
of GDM at high frequency, and more prevalence and co-
morbidity was observed of obesity with hypertension.
However, hypertension, lipid disorder, kidney and thyroid
diseases were found to be co-morbid with diabetes in
pregnancy at equal rate.
Nonetheless, the handling and care of pregnancy is
essential right of every woman and immediate relations
should be responsible and should play positive role for
saving mother and baby both. Firstly, proper meal plan and
supplements are basic need for healthy pregnancy.
Healthy diet with low glycemic index help to reduce the risk
of GDM and hypertension. Various social and economical
factors influence the diet and healthy environment for a
pregnant women. Unfortunately, in Pakistan, high poverty
rate, low income, and more dependence on one income
hinders in providing ideal conditions during pregnancy.
Thus, the present study showed that majority of the
population is deprived of healthy and good diet and
furthermore no essential supplements were consumed
after conception, and women are being consulted with
gynecologists in second or third trimester. All these factors
are cumulative cause to lead to high GDM rate in Pakistani
women.
C O N C L U S I O N
The outcomes of this study showed an increasing
incidence of GDM at older age pregnancy because of more
susceptibility towards hypertension and Type 2 DM.
Additionally, different socio-economic factors were also
observed to influence GDM rate including family income,
lifestyle, stress etc. that directly or indirectly affects the
health during and after the pregnancy. To overcome the
associated risks during pregnancy, health care programs,
plans, and campaigns should be arranged and healthcare
professionals should work to give awareness about
maternal and fetus health care.
Management of GDM and Trans-Generational Prevention Vol.12 (2), December 2021
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R A D S J . B i o l . R e s . A p p l . S c i . 152
E T H I C A L A P P R O V A L
All procedures were performed in accordance with the
ethical principles, and the study approved by the Faculty
Research Committee, Department of Pharmacology,
Jinnah Sindh Medical University, Karachi, (Ref. No.
JSMU/Pharma/151/2020). After verbal consent, the data
was collected and firmly preserved for the privacy of all
information given by participants. Ethical issues (informed
consent, misconduct, data assembly, etc.) have been fully
observed by the authors.
C O N F L I C T S O F I N T E R E S T
None.
F U N D I N G S O U R C E
None.
A C K N O W L E D G M E N T S
None.
L I S T O F A B B R E V I A T I O N S
DM Diabetes Mellitus
GDM Gestational Diabetes Mellitus
OGTT Oral Glucose Tolerance Test
SPSS Statistical Package for Social Sciences
R E F E R E N C E S
1. Deave T, Johnson D, Ingram J. Transition to
parenthood: The needs of parents in pregnancy and
early parenthood. BMC Pregnancy Childbirth. 2008;
8:30-9.
2. McLeish J, Redshaw M. Peer support during
pregnancy and early parenthood: A qualitative study of
models and perceptions. BMC Pregnancy Childbirth.
2015; 15:257-63.
3. Stoyles BJ. The value of pregnancy and the meaning
of pregnancy loss. J Soc Phil. 2015; 46(1):91-105.
4. Rowlands IJ, Redshaw M. Mode of birth and women's
psychological and physical wellbeing in the postnatal
period. BMC Pregnancy Childbirth. 2012; 12:138-43.
5. Yonkers KA, Gilstad-Hayden K, Forray A, Lipkind HS.
Association of panic disorder, generalized anxiety
disorder, and benzodiazepine treatment during
pregnancy with risk of adverse birth outcomes. JAMA
Psychiat. 2017; 74(11):1145-52.
6. Thombre KM, Holzman C, Wasilevich E, Luo Z, Scheid
J, Allswede M. Pregnancy hypertension and its
associations with pre-pregnancy depression, anxiety,
antidepressants, and anxiolytics. Preg Hypertens.
2019; 16:67-74.
7. Meyer H, Stadermann B. Energy and nutrient
requirement of mares during the late pregnancy.
Pferdeheilkunde (Germany, FR). 1991; 7(1):11-20.
8. Simmons D. GDM and nutrition-answered and
unanswered questions-There's more work to do! Nut.
2019; 11(8):1940-9.
9. Jang HC. Gestational diabetes in Korea: Incidence and
risk factors of diabetes in women with previous
gestational diabetes. Diabetes Metab J. 2011; 35(1):1-
7.
10. Huvinen E, Eriksson JG, Stach-Lempinen B, Tiitinen A,
Koivusalo SB. Heterogeneity of gestational diabetes
(GDM) and challenges in developing a GDM risk score.
Acta Diabetol. 2018; 55(12):1251-9.
11. Brown J, Alwan NA, West J, Brown S, McKinlay CJ,
Farrar D, et al. Lifestyle interventions for the treatment
of women with gestational diabetes. Cochrane
Database Syst Rev. 2017; 5(5):1-9.
12. Kampmann FB, Thuesen ACB, Hjort L, Bjerregaard
AA, Chavarro JE, Frystyk J, et al. Increased leptin,
decreased adiponectin and FGF21 concentrations in
adolescent offspring of women with gestational
diabetes. Eur J Endocrinol. 2019; 181(6):691-700.
13. Zhang C, Rawal S, Chong YS. Risk factors for
gestational diabetes: Is prevention possible?
Diabetologia. 2016; 59(7):1385-90.
14. Mijatovic-Vukas J, Capling L, Cheng S, Stamatakis E,
Louie J, Cheung NW, et al. Associations of diet and
physical activity with risk for gestational diabetes
mellitus: A systematic review and meta-analysis. Nut.
2018; 10(6):698-105.
15. Zhu Y, Zhang C. Prevalence of gestational diabetes
and risk of progression to Type 2 diabetes: A global
perspective. Curr Diab Rep. 2016; 16(1):7-15.
16. Horsch A, Gilbert L, Lanzi S, Gross J, Kayser B, Vial
Y, et al. Improving cardiometabolic and mental health
in women with gestational diabetes mellitus and their
offspring: Study protocol for MySweetHeart Trial, a
randomised controlled trial. BMJ Open. 2018; 8(2):1-8.
17. Catalano PM. Obesity, insulin resistance, and
pregnancy outcome. Rep. 2010; 140(3):365-71.
Management of GDM and Trans-Generational Prevention Vol.12 (2), December 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 153
18. American Diabetes Association Diagnosis and
classification of diabetes mellitus. Diabetes
Care. 2013; 36(Suppl. S1):S67-S74.
19. Plows JF, Stanley JL, Baker PN, Reynolds C, Vickers
MH. The pathophysiology of gestational diabetes
mellitus. Int J Mol Sci. 2018; 19:3342-9.
20. Svensson H, Wetterling L, Bosaeus M, Odén B, Odén
A, Jennische E, et al. Body fat mass and the proportion
of very large adipocytes in pregnant women are
associated with gestational insulin resistance. Int J
Obes. 2015; 40: 646-53.
21. De Souza LR, Berger H, Retnakaran R, Maguire JL,
Nathens A.B, Connelly P, et al. First-Trimester
maternal abdominal adiposity predicts dysglycemia
and gestational diabetes mellitus in
midpregnancy. Diab Care. 2015; 39:61-4.
22. Anonymous. Better diet before pregnancy lowers GDM
risk. Springer Healthcare News, 2012; 1(1):1-9.
23. Mustaniemi S, Vääräsmäki M, Eriksson JG, Gissler M,
Laivuori H, Ijäs H, et al. Polycystic ovary syndrome
and risk factors for gestational diabetes. Endocr
Connect. 2018; 7(7):859-69.
24. Foroozanfard F, Moosavi SG, Mansouri F,
Bazarganipour F. Obstetric and neonatal outcome in
pcos with gestational diabetes mellitus. J Family
Reprod Health. 2014; 8(1):7-12.
25. Issat T, Nowicka MA, Jakimiuk AJ. Polycystic ovary
syndrome (PCOS) and gestational diabetes mellitus
(GDM) risk. Ginekol Pol. 2015; 86(5):392-5.
26. Andersen M, Glintborg D. Diagnosis and follow-up of
type 2 diabetes in women with PCOS: A role for
OGTT? Eur J Endocrinol. 2018; 179(3):1-14.
27. Sandseter HL, Horn J, Rich-Edwards JW, Haugdahl
HS. Preeclampsia, gestational diabetes and later risk
of cardiovascular disease: Women's experiences and
motivation for lifestyle changes explored in focus group
interviews. BMC Preg Childbirth. 2019; 19(1):448-53.
28. Spradley FT. Metabolic abnormalities and obesity's
impact on the risk for developing preeclampsia. Am J
Physiol Regul Integr Comp Physiol. 2017; 312(1):5-12.
29. Weissgerber TL, Mudd LM. Preeclampsia and
diabetes. Curr Diab Rep. 2015;15(3):9-15.
30. Devarshi PP, Grant RW, Ikonte CJ, Hazels Mitmesser
S. Maternal omega-3 nutrition, placental transfer and
fetal brain development in gestational diabetes and
preeclampsia. Nut. 2019; 11(5):1107-12.
31. Moosazadeh M, Asemi Z, Lankarani KB, Tabrizi R,
Maharlouei N, Naghibzadeh-Tahami A, et al. Family
history of diabetes and the risk of gestational diabetes
mellitus in Iran: A systematic review and meta-
analysis. Diabetes Metab Syndr. 2017; 11 Suppl
1:S99-S104.
32. Musarrat R, Asmat N, Shabeen NM, Asher F, Abdul B,
Shera AS. Frequency of gestational diabetes mellitus
using DIPSI criteria, A study from Pakistan, Clin
Epidemiol Glob Heal. 2019; 7(2), 218-21.
33. Pace NP, Vassallo J, Calleja-Agius J. Gestational
diabetes, environmental temperature and climate
factors - From epidemiological evidence to
physiological mechanisms. Early Hum Dev. 2021;
155:105219-28.
34. Glezer A, Bronstein MD. Prolactinomas: How to handle
prior to and during pregnancy? Minerva Endocrinol.
2018; 43(4):423-9.
35. Ide M, Papapanou PN. Epidemiology of association
between maternal periodontal disease and adverse
pregnancy outcomes--systematic review. J
Periodontol. 2013; 84(4 Suppl):S181-94.
36. Blau LE, Lipsky LM, Dempster KW, Eisenberg Colman
MH, Siega-Riz AM, Faith MS, et al. Women's
experience and understanding of food cravings in
pregnancy: A qualitative study in women receiving
prenatal care at the University of North Carolina-
Chapel Hill. J Acad Nutr Diet. 2020; 120(5):815-24.
37. Hill AJ, Cairnduff V, McCance DR. Nutritional and
clinical associations of food cravings in pregnancy. J
Hum Nutr Diet. 2016; 29(3):281-9.
38. Mirzamoradi M, Saleh M, Jamali M, Bakhtiyari M,
Pooransari P, Saleh GS. Factors related to unwanted
pregnancies and abortion in the northern district of the
city of Tehran, Iran. Women Health. 2018; 58(6):714-
28.
39. Schneider S, Bock C, Wetzel M, Maul H, Loerbroks A.
The prevalence of gestational diabetes in advanced
economies. J Perinat Med. 2012; 40(5):511-20.
40. Lindsay RS, Loeken MR. Metformin use in pregnancy:
promises and uncertainties. Diabetologia. 2017;
60(9):1612-9.