الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Diabetes is the most common medical complication of pregnancy It occurs in between 5 and 10% of all pregnancies.
The precise mechanisms underlying GDM remain unknown. The hallmark of GDM is increased insulin resistance. Pregnancy hormones and other factors are thought to interfere with the action of insulin as they bind to the insulin receptors
Patient with GDM having increased insulin resistance can not compensate with increased insulin production in the β-cells of the pancreas.
Because glucose crosses the placenta, the fetus is exposed to higher glucose levels. This leads to increased fetal serum level of insulin. The growth stimulating effect of insulin can lead to macrosomia.
After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia).
Patient diagnosed with GDM have an increased risk of developing type II DM in the future.
Patient with GDM are also at risk for cardiovascular complications associated with abnormal serum lipids, hypertension, and abdominal obesity, this is called metabolic syndrome
GDM poses risks to both the mother and the fetus. These risks are mainly related to high blood glucose level and its consequences. The risks increase with higher blood glucose level. Treatment resulting in better control of blood glucose level can reduce some of the risks of GDM considerably
CRP is a circulating acute phase protein that reflects an active systemic inflammationmarked by increased serum levels of CRP is associated with insulin resistance, and prospective studies indicate that increased inflammation at baseline is an independent risk factor for the future development of type II DM
There is still debate about the use of CRP in early pregnancy as a predictive marker of subsequent GDM.
So this study tried to determine if the CRP level in the first trimester of pregnancy can be used as a predictor of subsequent GDM.
This study was conducted in morsalat dispensary
It is a longitudinal observational study which included 100 pregnant patients who were regularly attending the outpatient clinic for routine antenatal care.
In this study,there was no statistically significant relationship between CRP and the occurrence of GDM.
In India, Bhattacharya Sudhindra Mohan made a study in 2009. CRP was tested by latex-agglutination semi-quantitative method in early months of pregnancy in 91 patients. GDM was diagnosed by 3-hours glucose tolerance test between 24-28 weeks of pregnancy. Among the 91 women, 27 cases were CRP positive, out of whom, 4 cases developed GDM (14.8%). Among the 64 pregnant cases that were CRP negative, 7 cases developed GDM (10.9%).This was not statistically significant. So he concluded thatCRP in early months of pregnancy, as an inflammatory marker, is not a dependable screening test for development of GDM in later months of pregnancy. This study states the same results as our study.
In Boston, HarvardMedicalSchool, Myles Wolf et al conducted a prospective case control study in a pregnancy cohort in 2003. First-trimester CRP levels were measured using a high-resolution assay in 43 patients who subsequently developed GDM and in a random sample of 94 patients who remained euglycaemic throughout pregnancy. Median CRP levels were compared using Wilcoxon’s rank-sum test. First-trimester CRP levels were significantly increased among patients who subsequently developed GDM compared with control subjects. When BMI was included in the model, however, the association between increased CRP and GDM was attenuated. They concluded that in patients who developed GDM, there was evidence of increased inflammation during the first trimester. This association is mediated in part by increased BMI.
The results of this study were against ours, this may be due to variability in the number of cases, and the methodology. In addition, this study states that when BMI was included in the model, the association between increased CRP and GDM was attenuated so the increase in the CRP level was not the main risk factor for development of GDM.
ChunfangQiu et al in 2004 examined the association between CRP and development of GDM. Patients were recruited before 16 weeks gestation and were followed until delivery. Maternal serum CRP (collected at 13 weeks’ gestation, on average) was measured by a competitive immunoassay. Approximately 4.5% of the cohort (38 of 851) developed GDM. Elevated CRP was positively associated with GDM risk (P<0.01). After adjusting for maternal pre-pregnancy body mass index (BMI), family history of type II DM and nulliparity, patients with highest CRP levels experienced a 3.5-fold increased risk of GDM as compared with those having lowest CRP values. The association between CRP and GDM was evident when analyses were restricted to lean patients (BMI < 25 kg/m2). Lean patients with CRP 5.3 mg/L experienced a 3.7-fold increased risk of GDM as compared with patients with CRP < 5.3 mg/L. Systemic inflammation is associated with an increased risk of GDM, and the association is independent of maternal pre-pregnancy adiposity. The result of this study is against ours.
In this study, there was no statistically significant relationship between age and development of GDM.
InQueenMaryHospital, The University of Hong Kong, Terence T. Lao et al have reviewed the prevalence of GDM, diagnosed by the World Health Organization criteria in the singleton pregnancies managed from 1998 to 2001. The pregnancies were categorized according to maternal age, into 6 categories, ≤20 years, 20-24 years, 25-29 years, 30-34 years, 35-39 years, and >40 years. 15,827 (96.6%) patients continued their pregnancies beyond the first trimester, and the number (percentage of total) from the youngest to the oldest cohort were 318 (2.0%), 1,713 (10.8%), 4,446 (28.1%), 5,457 (34.5%), 3,279 (20.7%), and 614 (3.9%), respectively. There was a significant difference and positive correlation in the prevalence of GDM, increasing from 1.3, 2.5, 6.2, 10.3, 21.7, and 31.9%, respectively, from the youngest to the oldest cohort (P <0.001). The risk for the older cohorts was significantly increased as follows: 25–29 years, 2.59 (1.84 –3.67); 30–34 years, 4.38 (3.13– 6.13); 35–39 years, 10.85 (7.72–15.25); and >40 years, 15.90 (10.62–23.80). There was no significant difference for the ≤20 years cohort. These finding indicates that the risk of GDM becomes significantly and progressively increased from 25 years onwards. This supports the American Diabetes Association recommendation on the use of age 25 years as the cutoff for screening and the observation that maternal age 25 years is the factor most predictive of GDM.The results of this study were against ours, this may be due to variability in the number of cases.
In this study, there was no statistically significant relationship between weight gain and CRP .This is against the results of Simin Rota, et al in PamukkaleUniversity, Denizli, Turkey who studied 20 non-obese pregnant patients with GDM and 30 non-obese patients without GDM as a control group, the BMI of all subjects where < 25 kg/m2. During 26-28 weeks gestation, 100 gm Oral Glucose Test was performed and simultaneously fasting CRP levels were measured. Serum CRP level was higher in patients with GDM (P < 0.0001). CRP was strongly associated with glycaemic parameters & weight gain during pregnancy.
In this study, there was no statistically significant relationship between BMI and CRP. In University of Toronto, Canada, Ravi Retnakaran et al performed a cross sectional study to determine whethermarkers of subclinical inflammation are elevated in patientswith GDM. They studied 180 healthy pregnant women undergoingoral glucose tolerance testing in the late second or earlythird trimester. Based on Oral Glucose Tolerance Test andpre-pregnancy body mass index (BMI), participants were stratifiedinto four groups: 1) normal glucose tolerance (NGT) lean(BMI, <25 kg/m2) (n = 65ceses); 2) NGT overweight (n = 28cases); 3)impaired glucose tolerance (n = 39cases); and 4) GDM (n = 48cases).Median CRP level was highest in overweight NGT subjects (8.8mg/liter), followed by GDM (5.5 mg/liter), impaired glucosetolerance (4.4 mg/liter), and lean NGT (4.4 mg/liter). CRP was significantly correlated with pre-pregnancyBMI (P<0.0001), so pre-pregnancyBMI emerged as the most important determinant ofCRP concentration, whereas glycemic tolerance status wasnot a significant factor. In summary, they demonstratethat maternal serum levels of CRP are not related to GDM but rather correlate significantly with pre-pregnancy obesity. An independent contribution of CRP to risk of GDM could not be confirmed. The results of this study were against ours as regards the correlation between pre-pregnancyBMI and the CRP, but it agrees with our study that an independent contribution of CRP to risk the development of GDM could not be confirmed.
In University of Otago, New Zealand, MJA Williams et al conducted a cross-sectional study of a community cohort, 822 patients aged 26 years. Measurements of CRP, BMI, blood pressure, lipid and lipoprotein levels, smoking status, socioeconomic status, health status, and hormonal contraceptive use in patients were done. They found that obesity was independently related to CRP. The results of this study was against ours
In this study, there was statistically significant trend that overweight and obese pregnant patients had greater chance to develop GDM. This coincide with the result of Jenny S etalInHarvard Medical School, Boston, USA in 2008, who studied 1733 patients with singleton pregnancies enrolled in Project Viva .They examined the associations of first trimester diet, with results of glucose tolerance testing at 26−28 weeks gestation.91 patients developed GDM and 206 patients had impaired glucose tolerance (IGT). They concluded that Pre-pregnancy body mass index (BMI) is a strong predictor for development of GDM.
In Szczecin University, Poland, J. Ogonowski et al studied 1121 patients with GDM who were referred to the Outpatient Clinic between January 2001 and December 2005. The control group consisted of 1011 healthy pregnant women. All had singleton pregnancies. Significant relationships between pre-gravid BMI and GDM were found and BMI was the strongest predictor for GDM treated with insulin. Of all patients with GDM, 25.7% were treated with insulin. The percentage of patients requiring insulin therapy significantly increased with an increase of BMI across all studied categories. Therefore, Pre-gravid BMI is a strong predictor for GDM requiring insulin treatment. This study states the same results as our study.
In this study, there was highly statistically significant relation between weight gain and GDM as 50% of cases whose weight gain was between 7-9Kg developed GDM but only 5.6% of cases whose weight gain was between 4.5-6.5Kg developed GDM .In Sansum Diabetes Research Institute, California. Wendy C. et al Studied the effect of medical nutrition therapy (MNT) on insulin sensitivity. Weight gain was significantly correlated with a decrease in insulin Sensitivity. this means that there is a significant relation between weight gain and development of GDM. This study states the same results as our study.