Mursal Full Thesis
Mursal Full Thesis
BACHELOR OF NURSING
SCHOOL OF HEALTH SCIENCES
UNIVERSITI SAINS MALAYSIA
2021
PREVALENCE OF GESTATIONAL DIABETES MELLITUS
by
July 2021
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ACKNOWLEDGEMENT
Duangta A/P Shet and co-supervisor, Dr. Norhasmah Mohd Zain for always spending their
invaluable times and giving full support in guiding, supervising and encouragement
dissertation would not be able to accomplish without their assistance and dedicated
and giving me endless support throughout my study at Universiti Sains Malaysia. Moreover,
I would like to take this opportunity to thank Mr. Belonwu M. Onyenekwe for the approval
to use this questionnaire in this study. This questionnaire is an important aspect in this study.
Finally, I would like to appreciate for persons involved in this study, either directly
or indirectly, which included respondents that involved in this study, my friends that always
supporting me during handling difficult times in my journey and also those who helped and
guided me in every step to complete this dissertation especially in data analysis. I would like
to give the highest appreciation to them for their patience in providing a clear suggestion for
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TABLE OF CONTENT
CERTIFICATE ...................................................................................................................... ii
DECLARATION .................................................................................................................. iii
ACKNOWLEDGEMENT .....................................................................................................iv
TABLE OF CONTENT .......................................................................................................... v
LIST OF TABLES .............................................................................................................. viii
LIST OF FIGURES ...............................................................................................................ix
LIST OF ABBREVIATION ................................................................................................... x
ABSTRAK .............................................................................................................................xi
ABSTRACT......................................................................................................................... xii
CHAPTER 1 INTRODUCTION ............................................................................................ 1
1.1 Background of Study ................................................................................................ 1
1.2 Problem Statement .................................................................................................... 3
1.3 Research Question .................................................................................................... 5
1.4 Research Objective ................................................................................................... 5
1.4.1 General Objective .............................................................................................. 5
1.4.2 Specific Objectives ............................................................................................ 6
1.5 Research Hypotheses ................................................................................................ 6
1.6 Significance of the Study .......................................................................................... 7
1.7 Definition of Conceptual and Operational Terms..................................................... 9
CHAPTER 2 LITERATURE REVIEW ............................................................................... 11
2.1 Introduction ............................................................................................................. 11
2.2 Pathophysiology of Gestational Diabetes Mellitus (GDM) .................................... 11
2.3 Prevalence of Gestational Diabetes Mellitus (GDM) ............................................. 12
2.4 Diagnostic Criteria of Gestational Diabetes Mellitus (GDM) ................................ 15
2.5 Risk factors of Gestational Diabetes Mellitus (GDM) ........................................... 16
2.5.1 Demographic status of pregnant women ......................................................... 16
2.5.2 Lifestyles .......................................................................................................... 17
2.6 Management of Women with Gestational Diabetes Mellitus (GDM) .................... 20
2.6.1 GDM Management during Pregnancy ............................................................. 20
2.6.2 GDM Management after delivery .................................................................... 21
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2.7 Complication of Gestational Diabetes Mellitus to mother and infant .................... 21
2.8 Conceptual framework of the study ........................................................................ 23
CHAPTER 3 METHODOLOGY AND METHODS ........................................................... 27
3.1 Introduction ............................................................................................................. 27
3.2 Research design ...................................................................................................... 27
3.3 Study setting and population................................................................................... 28
3.4 Sampling Plan ......................................................................................................... 28
3.4.1 Sample criteria-Inclusion and exclusion criteria ............................................. 28
3.4.2 Sampling Size Estimation ................................................................................ 29
3.4.3 Sampling Method ............................................................................................. 31
3.5 Research Instrument ............................................................................................... 31
3.5.1 Instrument ........................................................................................................ 31
3.5.2 Translation of Instrument................................................................................. 32
3.5.3 Validity and Reliability of Instrument ............................................................. 33
3.6 Variables ................................................................................................................. 34
3.6.1 Measurement of Variables ............................................................................... 34
3.6.2 Variable Scoring .............................................................................................. 35
3.7 Data Collection Method .......................................................................................... 36
3.8 Ethical Consideration .............................................................................................. 38
3.9 Data Analysis .......................................................................................................... 40
CHAPTER 4 RESULTS ....................................................................................................... 41
4.1 Introduction ............................................................................................................. 41
4.2 Prevalence of Gestational Diabetes Mellitus .......................................................... 41
4.3 Sociodemographic characteristics........................................................................... 42
4.4 Family and health history ....................................................................................... 45
4.5 Knowledge of women regarding risk factors of GDM ........................................... 47
4.5 Dietary pattern ........................................................................................................ 48
4.6 Physical Activity Status .......................................................................................... 49
4.7 Association of risk factors of GDM and prevalence of GDM ................................ 50
CHAPTER 5 DISCUSSION ................................................................................................. 53
5.1 Introduction ............................................................................................................. 53
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5.2 Prevalence of Gestational Diabetes Mellitus (GDM) ............................................. 53
5.3 Association between prevalence of GDM and associated risk factors ................... 54
5.3.1 Association between demographic characteristics and prevalence of GDM ... 55
5.3.2 Lifestyles .......................................................................................................... 59
5.4 Strength and limitations of the study ...................................................................... 61
CHAPTER 6 CONCLUSION .............................................................................................. 63
6.1 Summary and findings of study .............................................................................. 63
6.2 Implications and recommendations ........................................................................ 64
6.2.1 Implication to Nursing practice ....................................................................... 64
6.2.2 Implication to Nursing education .................................................................... 65
6.2.3 Implication to Nursing research ....................................................................... 65
6.3 Conclusion .............................................................................................................. 66
REFERENCES ..................................................................................................................... 67
APPENDIX A PERMISSION FROM AUTHOR ................................................................ 75
APPENDIX B QUESTIONNAIRE ...................................................................................... 76
APPENDIX C: ETHICAL FORMS ..................................................................................... 85
LAMPIRAN A .............................................................................................................. 85
LAMPIRAN S .............................................................................................................. 89
LAMPIRAN P .............................................................................................................. 90
ATTACHMENT B ....................................................................................................... 91
ATTACHMENT S ........................................................................................................ 95
ATTACHMENT P ........................................................................................................ 96
APPENDIX D: INSTITUTIONAL APPROVAL ................................................................ 97
APPENDIX E ETHICAL APPROVAL ............................................................................... 99
APPENDIX F: GANTT CHART/PROJECT SCHEDULE ............................................... 102
APPENDIX G TRANSLATION OF THE QUESTIONNAIRE ........................................ 104
APPENDIX H: BROCHURE FOR RESPONDENTS ....................................................... 105
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LIST OF TABLES
Table 4.2: Fasting Glucose Level, Gestation Week that Diagnosed GDM and Management
Table 4.5: Answer of Women’s Knowledge on Risk Factors of Gestational Diabetes Mellitus
(GDM) (n=89)…………………………………………………………………...47
Table 4.6: Score of Women on Knowledge on Risk Factors of Gestational Diabetes Mellitus
(GDM) (n=89)…………………………………………………………………...48
Table 4.9: Association of Risk Factors of Gestational Diabetes Mellitus (GDM) and
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LIST OF FIGURES
Figure 2.2: Conceptual Framework of Study: Risk Assessment Model of GDM adapted from
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LIST OF ABBREVIATION
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KELAZIMAN GDM DAN FAKTOR RISIKO TERPILIH DI
KALANGAN WANITA YANG MENGANDUNG DI HOSPITAL
UNIVERSITI SAINS MALAYSIA
ABSTRAK
termasuk di Malaysia, dan faktor risiko yang berkaitan tidak diteroka secara mendalam. Hal
ini penting untuk merancang langkah-langkah pencegahan GDM secara berkesan, oleh itu,
Obstetrik dan Ginekologi sepanjang Disember 2020 hingga Februari 2021. Seramai 89
menggunakan borang soal selidik. Umur purata responden adalah 32 ± 5.8, berumur antara
21 hingga 46 tahun. Ujian Person’s Chi Square atau Fisher’s Exact digunakan untuk
menentukan hubungan antara faktor risiko terpilih dengan kelaziman GDM. Hasil kajian
menunjukkan bahawa kelaziman GDM adalah 33.7% dan majoritinya di bawah kawalan diet.
Hasil kajian juga menunjukkan bahawa ciri sosiodemografi tidak mempunyai statistik yang
signifikan dengan kelaziman GDM. Kajian ini juga menunjukkan tiada hubungan signifikan
antara Indeks Jisim Badan, status kehamilan, sejarah keluarga diabetes mellitus, pengetahuan
wanita mengenai faktor risiko GDM, pola diet dan aktiviti fizikal dengan kelaziman GDM
kecuali sejarah GDM yang lalu (p=0.016) antara wanita di Klinik Obstetrik dan Ginekologi,
Hospital Universiti Sains Malaysia. Kesimpulannya, kelaziman GDM adalah tinggi dan
sejarah GDM yang lalu berkait dengan GDM. Faktor risiko yang berkemungkinan
menyebabkan GDM harus dikenal pasti supaya intervensi pencegahan awal dapat dilakukan
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PREVALENCE OF GESTATIONAL DIABETES MELLITUS AND
SELECTED RISK FACTORS AMONG PREGNANT WOMEN IN
HOSPITAL UNIVERSITI SAINS MALAYSIA
ABSTRACT
The current prevalence of Gestational Diabetes Mellitus (GDM) was globally increasing
included in Malaysia, and its associated risk factors were not adequately studied. It is
important in the planning of preventive measures of GDM effectively thus, lowering the
Gynecology Clinic, Hospital Universiti Sains Malaysia from December 2020 to February
2021. A total of 89 respondents was purposively selected and the data was collected using a
structured self-administered questionnaire. The mean age of respondents was 32 years old
(SD= 5.8), with age ranging between 21 to 46 years old. Pearson’s Chi-Square or Fisher’s
exact test was used to determine the association of selected risk factors to the prevalence of
GDM. Results showed that the prevalence of GDM was 33.7% and majority of them were
on diet control. The results also showed sociodemographic characteristics were not
statistically significant associated with the prevalence of GDM. The study also revealed there
was no significant association between BMI, gestational status, family history of diabetes
mellitus, knowledge of women about risk factors of GDM, dietary pattern and physical
activities with the prevalence of GDM except the past history of GDM (p=0.016) among the
women in Obstetrics and Gynecology Clinic, Hospital Universiti Sains Malaysia. The
conclusion is that the prevalence of GDM is high and past history of GDM is associated with
GDM. Risk factors that may cause GDM should be recognized to allow early prevention
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CHAPTER 1
INTRODUCTION
This study was carried out to identify the prevalence of gestational diabetes mellitus
(GDM) and to assess selected risk factors of GDM. Chapter 1 details the background of the
study, problem statement, research objectives, research questions, research hypothesis, the
significance of this study and the definitions of the conceptual and operational terms.
defined as a state of hyperglycemia and glucose intolerance which first recognized or the first
onset during pregnancy (DeFronzo, Ferrannini, Zimmet & Alberti, 2015; Erem, Kuzu, Deger
& Can, 2015). Currently, the prevalence of GDM is still under investigation, that the true
prevalence of GDM remains unknown (Egbe, Tsaku, Tchounzou & Ngowe, 2018). The cause
of GDM is currently unknown, however, GDM may happen due to maternal adaptation to
pregnancy (DeFronzo et al., 2015). The most common risk factors that cause GDM globally
included high maternal age, women who have a family history of diabetes, women who have
previous GDM history during previous pregnancy and mothers with pre-pregnancy obesity
GDM may cause complications to both mother and the infant. The GDM mother may
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Page, 2012; Erem et al., 2015). While the infant of diabetes mother may develop macrosomia,
hypoglycemia, Respiratory Distress Syndrome (RDS) and birth trauma (Buchanan et al.,
2012; Erem et al., 2015). Children of GDM mothers have a higher prevalence to develop
obesity and impaired glucose tolerance during their childhood and adolescence (Erem et al.,
2015). Moreover, pregnant women tend to ingest more glucose during late pregnancy, results
suppressed level of glucagon, causing further insulin resistance (DeFronzo et al., 2015).
GDM happens because, during early pregnancy, maternal glucose supplies cross the placenta
through diffusion to supply glucose requirements of the fetus which may cause maternal
(DeFronzo et al., 2015). However, during the second half of pregnancy, insulin resistance
glucocorticoids and progesterone (DeFronzo et al., 2015). Hence, the women with GDM
have 6 to 7 times higher risk to develop type II diabetes in the year following the pregnancy
than the women with normal glucose tolerance even though the women return to
normoglycemia state after delivery (Erem et al., 2015; Gracelyn & N., 2016; Zhu & Zhang,
2016).
The prevalence of GDM should be identified to indicate the affected level among
pregnant women in Malaysia. Due to the threatening and life-long complications of GDM
towards both mother and infant, it is important to study the possible risk factors that may be
associated with GDM. By identifying the possible risk factors, preventive measures of these
risk factors can be taken, and hence lowering the prevalence of GDM among Malaysia
women.
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1.2 Problem Statement
The current prevalence of GDM remains unknown although many pieces of research
conducted. This is maybe due to the results of research conducted is not applicable to
generalize population or the GDM prevalence trends are not yet stable. The unsure global
trends should not be comparable due to the methodological issue of research conducted,
which is not standardized or lacks uniformity to obtain accurate comparison (dos Santos,
Madi, da Silva, Rodrigues Vergani, de Araujo & Garcia, 2020; Zhu & Zhang, 2016). The
factors such as genetic history, the population being studied and the environment the
population are in (Egbe et al., 2018; Erem et al., 2015; Onyenekwe, Young, Nwatu, Okafor,
Ugwueze & Chukwu, 2019). However, according to the research conducted by Logakodie,
Azahadi, Fuziah, Norizzati, Tan, Zienna et al. (2017), Egbe et al. (2018) and Versteegen
(2019), the prevalence of GDM among Malaysia, African and United States are increasing.
The prevalence of GDM globally should be determined as GDM may cause many
In past researches, higher maternal age, high Body Mass Index (BMI) or being obese,
high parity count, family history of diabetes, and having a history of GDM during previous
pregnancy are among the most common risk factors that cause GDM among pregnant women
(Ali, Mehrass, Al-Adhroey, Al-Shammakh & Amran, 2016; Erem et al., 2015; Logakodie et
al., 2017). Besides these risk factors, there are also other risk factors to be studied as stated
from the research done by Ali et al. (2016), Erem et al. (2015) and Logakodie et al.(2017)
such as low or high birth weight, smoking, physical inactivity, excess weight gain during
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pregnancy as well as socioeconomic factors such as education level, occupation and
household income.
However, the association between the prevalence of GDM and risk factors was not
adequately studied regionally and globally. In Malaysia, the research conducted to study
GDM was still in few numbers and this is not adequate to confirm the prevalence of GDM
and its association between risk factors of GDM stated. Hence, these risk factors need further
investigation and research to prove the association of these risk factors to the prevalence of
GDM. This is important to plan preventive measures of GDM effectively to lower the
This study will help in identifying the current prevalence of gestational diabetes of
pregnant women who visit the Obstetrics and Gynaecology (O&G) clinic in Hospital
Universiti Sains Malaysia (HUSM). This study aims to determine the prevalence of GDM
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1.3 Research Question
ii. What are the associated risk factors of GDM among pregnant women in Hospital
iii. What is the association between the prevalence of GDM and selected risk factors among
Research objectives are divided into general objective and specific objectives.
among pregnant women in Hospital Universiti Sains Malaysia (HUSM) and its associated
factors.
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1.4.2 Specific Objectives
ii. To determine the associated risk factors of GDM among pregnant women in Hospital
iii. To determine the association between the prevalence of GDM and selected risk factors
Null Hypothesis (Ho): There is no significant association between the prevalence of GDM
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1.6 Significance of the Study
A woman with GDM may have complications from GDM for herself as well as her
newborn. The common complications of GDM for mother included higher risk to develop
high blood pressure, pre-eclampsia and any type of diabetes after delivery especially Type II
diabetes. The woman with GDM may also have higher possibility to deliver her baby through
Cesarean section. While the complications of GDM for the infant are macrosomia or large
for gestational age, hypoglycemia, RDS during or shortly after birth, obesity and type II
diabetes later in childhood or adolescence. Some complications are irreversible and may be
fatal to mother and infant as the complication may cause secondary complications. Hence, it
considering the size of GDM and provide necessary treatment and management and revert
This study concerns the research gap about the prevalence and risk factors associated
with GDM which may influence the way and effectiveness of delivering care and
management towards GDM mother and their infant. Significantly, the effectiveness of care
and management of GDM will influence the development of complications for mother and
infant as well as the growth and development process of the children in later life. With this
concern, the purpose of this research is to determine the prevalence and associated risk factors
of GDM among pregnant women in HUSM. This will lead to better health outcomes for both
GDM affected not only the patient and her baby but her family members as well. This
is because family members are anxious about the serious complications from GDM and its
long-term health effect, especially severe hypoglycemia for the baby, which is one of the
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most serious effects for an infant of diabetes patient due to insulin prescription for the diabetic
mother. Severe hypoglycemia may cause an infant to experience seizures, which may cause
them to be unresponsive or lead to irrational behavior or even lead to fatal conditions, which
will further distressing family members. With holistic and individualized effective
management of GDM, prevention of GDM among pregnant women was monitored and
further minimizes the risk of GDM during pregnancy, hence, minimize the risk of
Prevention is better than cure. GDM was preventable through healthy lifestyles,
balance nutrition and regular monitoring of blood sugar level. This study contributes to the
understanding of trends of GDM and associated risk factors that may cause GDM, hence help
in creating awareness of the society about GDM and improve their knowledge regarding
GDM. In this way, trends of GDM may become stable and even decreasing as society are
This research was also providing a guideline to other researchers that study similar
issue about GDM. Researchers can refer to and modify the strength and weaknesses of this
study to develop more uniform and holistic tools to determine the real regional trends of
GDM. This play a role in improving healthcare delivery system to the patient with GDM,
their infants and family members so that complications from this growing disease can
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1.7 Definition of Conceptual and Operational Terms
Definitions for the operational terms used in this research proposal are as follow:
clinic in HUSM.
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Risk factor : Risk factor is a type of correlate associated with an
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CHAPTER 2
LITERATURE REVIEW
2.1 Introduction
This chapter discusses about gestational diabetes, its prevalence, associated risk
factors and complications of this disease to the mother and infant. This chapter also described
There are changes in body physiology and hormone changes during pregnancy.
Insulin resistance in pregnancy may due to maternal obesity. Obesity may cause changes in
(Mirghani Dirar & Doupis, 2017; Molęda, Fronczyk, Safranow & Majkowska, 2015). This
is because obesity is recognized by the body as a chronic inflammatory state, which then
produced excessive inflammatory markers, and causes insulin resistance (Abell, De Courten,
Boyle & Teede, 2015; Mirghani Dirar & Doupis, 2017). Adipocytokines influence glucose
and insulin receptor, hence, developing insulin resistance (Mirghani Dirar & Doupis, 2017).
A low maternal level of adiponectin was also associated with insulin resistance (Mirghani
Dirar & Doupis, 2017). Tumor necrosis factor-α (TNF-α) also interferes the insulin receptor
women (Mirghani Dirar & Doupis, 2017). In the study by Mirghani Dirar & Doupis (2017)
and Mmorisset, Dubé, Côté, Robitaille, Weisnagel & Tchernof (2011), Interleukin-6, an
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inflammatory marker, is found significantly high in GDM women than women that do not
have GDM.
cortisol, estrogens and progesterone (Mirghani Dirar & Doupis, 2017; Ngala, Fondjo,
Gmagna, Ghartey & Awe, 2017). These placental hormones may cause the enlargement of
islets of Langerhans cells, or also known as pancreatic β-cell hyperplasia (Ngala et al., 2017).
& Doupis, 2017). This condition is best explained by insulin resistance that caused by the
Based on the worldwide studies done before, the prevalence of GDM in many
countries are increasing, this included African (Egbe et al., 2018), United States (Versteegen,
2019) and Malaysia (Logakodie et al., 2017), and the rate of GDM in the general population
is parallel to the rate in pregnancy (Meharry, Tengera, Rulisa, Byambu, Nietert, Byiringiro
et al., 2019). Many studies conducted also concluded that the prevalence of GDM is
increasing globally (Debnath, Talukder, Islam, Khan, Sabuj & Jhorna, 2018; Egbe et al., 2018;
Gracelyn & N., 2016; Leng, Shao, Zhang, Tian, Zhang, Zhang et al., 2015), however there
was no evidence to support the statement, although there are few studies that claimed the
prevalence of GDM in their country increasing. Besides, the prevalence of GDM globally
had a wide variation, which varied from 1% to 28% (Ali et al., 2016; Debnath et al., 2018;
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Onyenekwe et al., 2019), depending on the populations and diagnostic technique taken, hence
For example, the prevalence of GDM in some African countries reported 9.5% in
Tanzania and 8.2% in Nigeria (Zhu & Zhang, 2016). However, there are variations reported
in the same area by another study conducted by Egbe et al. (2018), which is ranged from 0%
in Tanzania to 13.9% in Nigeria. Systemic review done in six countries of Africa reported
that the overall prevalence rate of GDM in Africa is 5% to 6.3% (Egbe et al., 2018; Meharry
et al., 2019). Another systemic review done in Sub-Saharan Africa in 2011 reported the
Ramaiya & Feskens, 2015). Recent studies done stated that the prevalence rate of GDM in
2017) and 9.1% in South Africa (Farrar, Duley, Dowswell & Lawlor, 2017).
Central and South America reported 16.6% and 5.7% in Cuba and Brazil respectively
(Zhu & Zhang, 2016), however, another study conducted by Larrabure-Torrealva, Martinez,
Luque-Fernandez, Sanchez, Mascaro, Ingar et al. (2018) in Peru stated that the overall
estimated prevalence of GDM in Central and South America is approximately 11%. A study
by dos Santos et al. (2020) shows that the prevalence of GDM in a city in Brazil during 2016
by Zhu & Zhang (2016) in 2016 which is 5.7%. Hence, the prevalence of GDM in Brazil had
no significant changes from 2016 to 2020. United States recorded 3.74% to 7.15% variation
(Bardenheier, Elixhauser, Imperatore, Devlin, Kuklina, Geiss et al., 2013). However, a study
conducted by (Zhang, Tobias, Chavarro, Bao, Wang, Ley et al., 2014) recorded 1.1% to
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25.5% in Unites States, which is wider variation of prevalence than prevalence by
Bardenheier et al. (2013) in 2013. In contrast, general prevalence of GDM in United States
Yong, Mohd Shariff, Rejali, Mohd Yusof, Yasmin & Palaniveloo (2018).
The prevalence of GDM in Asia is higher than in European countries (5.4%) but lower
than in African (14.0%) (Lee et al., 2018). Besides African, published report shows the
variation of GDM prevalence in most Arabian countries, which is between 4.2% to 24.9% in
United Arab Emirates, Oman, Qatar, Bahrain, Kuwait and Arabia (Ali et al., 2016). A meta-
analysis done in 20 Asian countries reported that the prevalence in Saudi Arabia is 22.9%,
which is the third-highest among the Asian countries studied (Lee et al., 2018). Malaysia
recorded the highest prevalence of GDM among Southeast Asian countries, which is 18.3%,
followed by India (13.6%), Bangladesh (9.7%) and Sri Lanka (8.1%) (Zhu & Zhang, 2016).
Another study done by Debnath et al. (2018) shows that the prevalence of GDM in
Bangladesh (9.7%) is higher than in India which ranged from 3.8% to 8.3%. However, in
2018, Malaysia recorded the second highest prevalence of GDM among Southeast Asian
country which is 18.3%, followed by Singapore (17.6%) and Thailand (17.1%) (Lee et al.,
2018). Besides, a study conducted in Malaysia in 2019 stated that Malaysia’s prevalence of
GDM is relatively higher than most of the western countries, which recorded 11.4% to 18.3%
in a Selangor university hospital and a public health clinic (Hassan, Ching, Ling, Jaffar &
Lee, 2019).
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(Onyenekwe et al., 2019). Hence, it is important to set uniform international guidelines in
diagnosing GDM to ensure the validity and accuracy of each study done.
There are two criteria for diagnosing GDM used by most institutions, which are
World Health Organization (WHO) criteria, American Diabetes Association (ADA) criteria
2013 criteria recommended one-step method. WHO defines criteria for diagnosis of GDM as
in any stage of pregnancy, fasting glucose in plasma is over 126 mg/dl (7.0 mmol/L), reading
in 75g OGTT of plasma glucose reading more than 180 mg/dl (10.0 mmol/L) after an hour
and 200 mg/dl (11.1 mmol/L) after two hours (Karaçam & Çelİk, 2019; World Health
after fasting at least 8 hours (Gracelyn & N., 2016; Karaçam & Çelİk, 2019). ADA or
IADPSG recommend the diagnostic criteria of GDM that women with fasting plasma
glucose values exceeded 92 mg/dl (5.1 mmol/L), exceeded 180 mg/dl (10.0 mmol/L) of
plasma glucose values after an hour of OGTT and exceeded 153 mg/dl (8.5 mmol/L) of
plasma glucose values after two hours of OGTT (Gracelyn & N., 2016; Karaçam & Çelİk,
2019; Metzger, 2010; Muche et al., 2020). ADA also recommended using 2-step approach
for those having positive testing for 1 hour OGTT (Alsaedi, Altalhi, Nabrawi, Aldainy &
Wali, 2020).
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2.5 Risk factors of Gestational Diabetes Mellitus (GDM)
Previous study recognizes a few risk factors that lead to GDM such as advanced
maternal age, positive family history of diabetes mellitus, previous history of GDM, parity
status, low economic status, increasing maternal BMI, socioeconomic status of pregnant
mother and lifestyles of the pregnant women. In this subtitle, these risk factors will be
discussed in detail.
One of the risk factors of developing GDM is maternal age (Adam & Rheeder, 2017;
Bardenheier et al., 2013; Debnath et al., 2018; Larrabure-Torrealva et al., 2018; Price, Lock,
Archer & Ahmed, 2017). According to studies, the prevalence of GDM among women with
age group 35 years old to 45 years old is 45% (Bener, Saleh & Al-Hamaq, 2011). 31.7% of
pregnant women with GDM are within this age group in another study (Teh, Teede, Paul,
Harrison, Wallace & Allan, 2011). Based on these studies, advanced maternal age group,
which is between 35 years old to 45 years old, was significant risk factor of GDM.
Women with positive family history of diabetes mellitus are also at higher risk to
develop GDM (Adam & Rheeder, 2017; Debnath et al., 2018; Price et al., 2017). In Bener et
al. (2011) study, 31.7% of the respondent with GDM had positive family history of diabetes
mellitus, compared to 12.8% in normal women. In Teh et al. (2011) study, the women with
GDM and had positive family history of diabetes mellitus are two-fold compared to women
with GDM but with negative family history of diabetes mellitus. The highest proportion of
recognizing family history of diabetes mellitus as one of the risk factors of GDM is 49% in
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Price et al. (2017) study. The high percentage from these studies is determining the usefulness
There are studies shows that 30% to 60% of women with history of GDM in previous
gestation will develop GDM in the next gestations (Padayachee, 2015; Price et al., 2017;
Reece, 2010; Zhu & Zhang, 2016). Besides, most GDM mothers are multigravida (71.6%)
previous studies in Asia, GDM women with multigravida were 63.1% to 87.6% (Parhofer et
Some studies reported socioeconomic status influence the prevalence of GDM (Bener
et al., 2011; Teh et al., 2011). Most GDM women had lower economic status although there
was no significant relationship between the level of education and occupation with GDM,
however, these can be risk factors of GDM as women in lower socioeconomic status more
likely to have poorer understanding and controlling of diabetes (Bener et al., 2011). This can
be shown using the study by Larrabure-Torrealva et al. (2018) that women that had lower
2.5.2 Lifestyles
Lifestyle factors that included in this study included body weight, dietary pattern,
exercise and smoking habit, which are modifiable. In the study conducted by Meltzer (2014)
and Zhang et al. (2014), there was strong evidence to support that these four lifestyle factors
are playing role in the development of GDM. Women with healthy body weight, adherence
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to healthy dietary pattern, having regular exercise and do not smoke are in the category of
low-risk lifestyle factors and have 41% lower risk to develop GDM compared to other
Healthy body weight is when a women’s BMI is less than 25, which the woman is
not being overweight or obese (Meltzer, 2014; Zhang et al., 2014). Women with GDM were
significantly more overweight or being obese compared to those without diabetes (Bener et
al., 2011; Meharry et al., 2019). It is significantly affected the risk to develop GDM if
pregnant women have higher BMI or being obese (BMI more than 30) (Egbe et al., 2018;
Farrar et al., 2017; Pastakia et al., 2017; Price et al., 2017; Yong et al., 2018). 59.2% of
pregnant women with significant overweight or obesity is developed GDM (Bener et al.,
2011). Women who start their pregnancy with a healthy body weight and healthy lifestyle
are 52% lower risk to develop GDM (Meltzer, 2014; Zhang et al., 2014). However, BMI of
a person may be affected by the sedentary lifestyles and their dietary habit which are in
Good dietary intake during pregnancy will also reduce the risk of developing GDM
among pregnant women. Intake of nutritional-rich and energized food is relatively more
important than offering a large amount of food (Yong, Shariff, Yusof, Rejali, Appannah,
Bindels et al., 2020). Assessment of dietary intake during pregnancy is by assessing the
intakes of energy, macro-nutrients and micro-nutrients of food groups (Yong et al., 2020). A
prudent diet which is fat and cholesterol controlling diet, rich in vegetables, fruits, legumes,
fish, whole grains and low-fat dairy products, rather than processed foods, red meats, high
concentrated sweets and butter, are higher in nutrient contents and hence, provide a lower
risk of developing GDM (Du, Jiang, Karmin, Chen, Xu, Liu et al., 2017; He, Yuan, Chen,
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Lu, Hu, Mai et al., 2015; Tryggvadottir, Medek, Birgisdottir, Geirsson & Gunnarsdottir,
2016).
Physical activity had known direct and indirect impacts on insulin sensitivity and
glucose homeostasis (Padmapriya, Bernard, Liang, Loy, Cai, Zhe et al., 2017). Women that
have regular exercise or physical activities are at 50% lower risk to develop GDM (Meharry
et al., 2019; Padmapriya et al., 2017). Based on the study done by Padayachee (2015),
pregnant women that having sedentary lifestyles are two-fold higher risk to develop GDM
compare to active pregnant women. Low-risk usual exercise is defined as an exercise at least
one and a half-hour of vigorous or moderate physical activity a day for at least five days a
week, which equates to 150 minutes per week such as brisk walking, strengthening exercises,
dancing, swimming and chair exercises (Meltzer, 2014; Padayachee, 2015; Padmapriya et al.,
2017; Zhang et al., 2014). However, pregnant women in second and third trimester should
avoid activities that involved lying on their back as well as weight-bearing exercises
(Padayachee, 2015).
with hyperinsulinism and insulin resistance in some studies (Erem et al., 2015; Leng et al.,
2015). Some study shows that there is an association between cigarette smoking and the
prevalence of GDM, in contrast, the study by Erem et al. (2015) shows an inverse association
between smoking and GDM. This condition may due to alteration of body metabolism due
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2.6 Management of Women with Gestational Diabetes Mellitus (GDM)
Management of women with GDM during pregnancy and after pregnancy will be
blood glucose level, physical activities and insulin treatment. GDM management after
pregnancy involved screening of diabetes six weeks after delivery and lifestyle modification.
complications to both mother and infant (Alkassheh, 2014). The best way of maintaining
normal glucose levels during pregnancy is self-monitoring of blood glucose level, sufficient
and tolerance exercise and insulin treatment (Alkassheh, 2014; Hod, Kapur, Sacks, Hadar,
Agarwal, Di Renzo et al., 2015). Women should understand the importance of self-
monitoring of glucose level to reduce complications to themselves and their infant. Some
al., 2012). Pregnant women with GDM should regularly have tolerated physical activity to
reduce blood glucose levels (Alkassheh, 2014). Insulin therapy is required when blood
glucose cannot be controlled through diet modifying and oral anti-diabetic drug and should
be individualized to prevent complications from the treatment itself (Hod et al., 2015).
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2.6.2 GDM Management after delivery
Women with GDM are at high risk to develop type 2 diabetes after delivery, hence,
women with GDM should be screened for diabetes six weeks post-delivery (Alkassheh,
2014). Besides, life style modification should be planned for women with GDM after delivery
especially those who obese or overweight for dietary modification and physical activity after
delivery aims to reduce blood glucose level to normal range and minimize the risk of diabetes
in the future (Alkassheh, 2014; Murakami, Shionoya, Komenoi, Suzuki & Sakane, 2016;
GDM may cause many complications to both mother and infant, which some
complications are lifelong effects for the mother and the infant. The main complications of
GDM to mother including 8-fold of risk to develop eclampsia or pre-eclampsia, birth canal
injuries and cesarean section (86%) due to large fetus, polyhydramnios and cardiovascular
Hashemi, 2016; Begum, Dey & Fatema, 2018; Domanski, Lange, Ittermann, Allenberg, Spoo,
Zygmunt et al., 2018; Padmapriya et al., 2017). Women with GDM are 50% higher risk to
develop type II diabetes in their later life (Badakhsh et al., 2016; Padmapriya et al., 2017).
According to the study, one-third of mothers who had GDM develop type II diabetes as soon
as they deliver their baby (Badakhsh et al., 2016; Ferrara, Hedderson, Brown, Albright,
Ehrlich, Tsai et al., 2016). Another study stated that there are more than 50% of women with
GDM progress toward type I or type II diabetes after 5 to 10 years with higher prevalence
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(Badakhsh et al., 2016; Bener et al., 2011; Finer, Mathews, Lowe, Smart, Hillman, Foo et al.,
2014).
An infant of diabetic mother (IDM) is at higher risk (11.1% versus 6.96%) for preterm
birth (Domanski et al., 2018; Maqbali, 2018). Macrosomia (about 28%), neonatal
hypoglycemia (ranged from 25% to 48%) and embryonic jaundice (20%) are common in
IDM (Badakhsh et al., 2016; Begum et al., 2018; Malhotra & Stewart, 2015; Padmapriya et
al., 2017). There are some studies reported that severe GDM is related to increased risk of
stillbirth in the last two months of gestation and GDM causes the risk of pre-eclampsia
twofold (Badakhsh et al., 2016; Hogg, Price & Robinson, 2014). IDM also are in 17-fold to
develop type II diabetes in their later life (Bener et al., 2011; Malhotra & Stewart, 2015;
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2.8 Conceptual framework of the study
of time, given that the individual is alive and disease-free at the start of period of time
(Monson Cleaver, Abrams, Bingham, Buffler, Cardis et al., 2006). Risk assessment is
important especially in healthcare to identify the hazard and individuals at risk for a specific
disease. Once the risk is identified, it is vital to score and rank based on their occurrence and
its impact to promote effective interventions to prevent the risk (NEJM Catalyst, 2018). To
gather health information, health risk assessment or also known as health risk appraisal is
used to assess an individual’s health status, risks and habits (Schillling, 2005).
Krist and Woolf (2011) described a five-phase health assessment process, which
included patient information collection through health risk assessment tools, integration of
clinical and risk-reduction interventions to the patient and decision making of the patient
regarding his or her health. Hence, the important elements of health risk assessment are their
(Bregendahl, Orlando & Palaniappan, 2017). Family history is the strongest predictor of most
chronic diseases such as diabetes mellitus because most chronic diseases have a genetic
origin (Bregendahl et al., 2017). A holistic risk assessment model helps reduce healthcare
costs as well as reduce disability and mortality through effective prevention interventions
such as follow-up planning and modifying lifestyle behaviors (Goetzel et al., 2011).
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Risk appraisal model of GDM is not fully developed. However, some studies
summarized possible risk factors and complications of GDM in a flow chart which is shown
in Figure 2.1 (Nahavandi, Price, Sumithran & Ekinci, 2019). The model shows that the
pathophysiology of diabetes mellitus, which is insulin resistance caused by many factors such
as pregnancy and change in pregnancy hormones level. The model then connects the maternal
risk factors that possibly cause GDM such as obesity, advanced age, gestational weight gain
and ethnicity. From those risk factors, the model then rules out what are the possible long-
term and short-term complications for the mother and IDM. For example, higher risk to
develop type 2 diabetes for the mother in later life and neonatal hypoglycemia for her baby.
Figure 2.2 shows the adapted risk appraisal model of GDM that used in this study to
guide the process of research. Overall, the prevalence of GDM is a dependent variable that
is affected by independent variables, which are the risk factors that may cause GDM, as
shown in Figure 2.2. The complications of GDM to both mother and infant were expressed
in the figure to shows the importance of risk assessment of GDM in reducing morbidity and
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