Effect of maternal alcohol consumption on gestational diabetes detection and mother-infant’s outcomes in Kinshasa, DR Congo

doi:10.4236/ojog.2011.14040

Paper Menu >>

Journal Menu >>

Open Journal of Obstetrics and Gynecology, 2011, 1, 208-212

doi:10.4236/ojog.2011.14040 Published Online December 2011 (http://www.SciRP.org/journal/ojog/

OJOG

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG

Effect of maternal alcohol consumption on gestational

diabetes detection and mother-infant’s outcomes in

Kinshasa, DR Congo

Tandu-Umba Barthélémy*, Mbangama Muela Andy, Mbungu Mwimba Roger

Department of OB-GYN, University Clinics, Kinshasa, Congo.

Email: *[email protected]

Received 11 August 2011; revised 28 September 2011; accepted 16 October 2011.

ABSTRACT

Objectives: Since it has been suggested that moderate

alcohol drinking would increase insulin sensitivity,

which could benefit Gestational Diabetes Mellitus

(GDM), the study aimed at evaluating alcohol con-

sumption during pregnancy, and seeing whether this

consumption influences GDM detection and mater-

nal/perinatal outcomes. Study design: Women with

already known diabetes and those with multiple pre-

gnancy were excluded. All other pregnant women

attending antenatal care unit of the university clinics,

Kinshasa, DR Congo during the period from 1 March

throughout 31 October 2010, were invited at 24-week

gestation to enroll in O’Sullivan blood glucose testing

and if eligible in 100-gram oral glucose tolerance test.

Alcohol consumption, risk factors for GDM, and ge-

neral characteristics such as age, parity, gestity, BMI,

fat mass were registered. Diagnosed GDM was first

treated with diet and exercise, thereafter with Met-

formin, and if necessary with insulin. For other (nor-

mal) women data remained blinded until confinement.

Maternal and infant’s adverse outcomes such as ma-

ternal urinary infection, preeclampsia, cesarean sec-

tion, intrauterine growth retardation, birth weight <

2500 g, birth weight ≥ 3800 g (as stated > percentile

90 in our milieu), Apgar score at the first minute < 7,

shoulder dystocia or other birth injury, neonatal hy-

poglycemia and fetal alcohol syndrome (FAS) were

compared and analyzed according to GDM diagnosis

as well to alcohol status. Results: Up to 240 pregnant

women accepted to enroll into the study. Alcohol con-

sumption concerned 78 (32.5%) of the women, most

of them (61 = 25.42%) being heavy consumers. Risk

factors for GDM and Physical and blood glucose

characteristics were alike (p not significant) in both

consumers and non consumers, except for history of

HTA in the family that was significantly more fre-

quent (p = 0.02) among drinkers. GDM’s prevalence

was 9%. No adverse outcome was more prominent in

any subgroup, except Apgar score < 7 at the first

minute that was more frequent (p = 0.038) among

neonates of GDM mothers. No FAS, neither shoulder

dystocia nor neonatal hypoglycemia were diagnosed.

When alcohol status was considered, Birthweight ≥

3800 g was found more frequent (p = 0.0284) in alco-

hol consumers than in abstainers. Risk of this out-

come was three times higher when history of family

hypertension was present (odds ratio 2.694; CI: 0.536

- 13.544). Conclusions: The prevalence of alcohol con-

sumption by pregnant women of our series (32.5%)

seems not to impact the detection of GDM (9%). FAS

was not diagnosed. Lack of significant differences in

adverse outcomes between GDM and non GDM could

be attributed to huge follow-up of GDM women. In-

fluence of alcohol consumption on birth weight mo-

stly in setting of familial history of hypertension re-

mains to be addressed.

Keywords: Pregnancy; Alcohol Consumption; GDM;

Mother-Infant’s Outcomes

1. INTRODUCTION

Alcohol is a potent teratogen in humans and both mode-

rate and high levels of alcohol intake during early preg-

nancy may result in alterations of growth and morpho-

genesis in the fetus, including the so called fetal alcohol

syndrome (FAS) [1-5]. In neonates this syndrome is known

as microcephaly associating characteristic face made of

short palpebral fissures, sunken nasal bridge, short nose,

flattening of the cheekbones and midface, smoothing and

elongation of the ridged area (the philtrum) between the

nose and lips, and smooth, thin upper lip.

Previously, it has been suggested that moderate drin-

king would increase insulin sensitivity [6], but no study

questioned it as protective or adverse factor on either de-

tection or survey of Gestational Diabetes Mellitus (GDM)

T.-U. Barthélémy et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 208-212 209

which is known as a situation of low insulin sensitivity.

This study aims at three issues: to evaluate the impor-

tance of alcohol consumption by pregnant women in our

milieu; to determine whether alcohol consumption dur-

ing pregnancy influences GDM detection; to determine

its influences on maternal and infant’s outcomes among

GDM women.

2. MATERIALS AND METHODS

This observational study was approved by the institu-

tional review board of the faculty of medicine, Univer-

sity of Kinshasa. Women with already known diabetes

were excluded. Multiple pregnancies were also excluded.

All other pregnant women attending antenatal care unit

of the university clinics, Kinshasa, DR Congo during the

period from 1 March throughout 31 October 2010, were

invited to enroll in 50-gram glucose O’Sullivan testing at

24-week gestation (calculated from the last menstrual

period and early ultrasound examination data). Venous

blood glucose was assayed by use of One Touch Profile

Meters (Lifescan, Johnson & Johnson, High Wycombe,

U.K.). Based on this testing GDM was defined as blood

glucose ≥ 200 mg/dL. Women with values between 140

mg/dL and 199 mg/dL (n = 38) were encouraged to join

a 100-gram oral glucose tolerance test (OGTT).

Alcohol consumption was quoted as light (less than 1

litre but more than 30 cl/day) or heavy (more than 1

l/day) [3-5] and no counseling was initiated for drinkers.

Maternal characteristics included age, parity, gestity,

body mass index (BMI calculated as [weight (kg)/height

(m)2]), and fat mass according to impedancimetry (with

an OMRON BF 300 impedance meter). Risk factors for

GDM were also registered: obesity (BMI > 25), family-

history of diabetes (grandparents, parents, brothers, sis-

ters), or of arterial hypertension (HTA), previous history

of polyhydramnios, infant’s birth weight ≥ 3800 g (>

90th percentile in our milieu), stillbirth and congenital

malformation. Diagnosed GDM was first treated with

diet and exercise, aiming to achieve a fasting blood glu-

cose lower than 95 mg/dL, thereafter with MetforminR,

and if necessary with insulin. For other (normal) women

data remained blinded until confinement. Weight of the

newborn was measured immediately after birth. Infants

were examined, and judged clinically as having or not

signs of effect of alcohol on morphogenesis.

2.1. Maternal and Infant’s Adverse Outcomes

Such as maternal urinary infection, preeclampsia, cesar-

ean section, intrauterine growth retardation (IUGR), bir-

th weight ≥ 3800 g, Apgar score < 7 at the first minute,

shoulder dystocia or other birth injury, clinical neonatal

hypoglycemia and FAS were compared according to

both GDM and alcohol status.

2.2. Statistical Analysis (p < 0.05 Significant)

Differences between means were calculated using Stu-

dent’s t test (for normally distributed results) or other-

wise according to Mann-Whitney test. Differences be-

tween proportions were calculated according to chi-

square or Fischer’s exact test where appropriate. Multi-

variate adjusted odds ratios (95% confidence interval)

were used to eliminate influence of variables that could

modify effect of alcohol consumption on GDM diagno-

sis as well as on maternal and infant’s adverse outcomes.

3. RESULTS

Up to 240 pregnant women accepted to enroll into the

study. Their gestational age at delivery ranged from 37

to 41 weeks. Gestational age at recruitment was 30.78 ±

4.6 weeks. The birth weight at term was 3132.97 ± 470.1

g. Other characteristics means at recruitment are pre-

sented in Table 1.

Table 1. Maternal characteristics according to alcohol status (Mean ± Standard deviation).

Overall

oup

(n =

240) A

oho

absta

(n =

162) A

oho

(n =

78)

p values

Age (yrs) 31.25 ± 4.9 30.94 ± 5.03 31.88 ± 4.6 0.1699

Parity 1.99 ± 1.84 1.93 ± 1.89 2.1 ± 1.7 0.5041

Gestity 3.0 ± 2.08 2.85 ± 2.17 3.29 ± 1.8 0.1244

BMI (kg/m2) 24.73 ± 4.4 24.65 ± 4.3 24.88 ± 4.6 0.7051

Fat mass (kg) 19.88 ± 7.7 19.6 ± 7.6 20.45 ± 7.8 0.4326

Fat mass (%) 27.5 ± 6.5 27.5 ± 6.2 27.8 ± 7 0.7190

Plasma glucose during O’Sullivan (mg/dL) 121.10 ± 30.7 122.2 ± 31.2 121.9 ± 30.8 0.4071

GDM after O’Sullivan 6 5 (3.1%) 1 (1.3%) 0.7190

GDM after OGTT 15 10 (6.2%) 5 (6.4%) 0.4071

GDM 21 13 (8%) 8 (10.2%) 0.6071

T.-U. Barthélémy et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 208-212

210

Alcohol consumption concerned 78 (32.5%) of the

women attending our antenatal care unit, most of them

(61 = 25.42% of the overall series) being heavy con-

sumers. Beer was the only type of beverage reported.

The most invoked reason for alcohol consumption was

the prevention of discomforting nausea and vomiting.

No significant difference was found between alcohol

consumers and abstainers. Out of 240 women registered

for O’Sullivan testing 6 were recognized GDM (≥200

mg/dL of blood glucose value) and 188 were O’Sullivan

negative (glucose values less than 140 mg/dL). Among

46 women who had glucose values ranging from 140

mg/dL and 199 mg/dL 11 failed to join OGTT and were

excluded for the calculation of GDM’s prevalence which

thus concerned 6 women diagnosed after O’Sullivan

testing and 15 after OGTT (21/229 = 9%).

Risk factors for GDM were alike (p not significant) in

both alcohol consumers and non consumers, except for

familial history of HTA that was more frequent (p = 0.02)

among drinkers (Table 2).

Eight women who delivered before term or at another

maternity were excluded for mother/infant’s outcomes

assessment, which thus restricted further calculations to

221 mother/infant couples (Tables 3-4).

No adverse outcome was more prominent in any sub-

group, except Apgar score < 7 at the first minute that

was more frequent (p = 0.038) among neonates of GDM

mothers. No FAS, neither shoulder dystocia nor neonatal

hypoglycemia were diagnosed. When alcohol status was

considered (Table 4), birth weight ≥ 3800 g was found

more frequent in alcohol consumers than in abstainers (p

= 0.0284). Since maternal history of HTA in the family

was the only risk factor for GDM more frequent (p =

0.02) among drinkers, its influence on prominent APO

(Preeclampsia, Apgar at the first minute < 7, birth weight

≥ 3800 g) according to alcohol consumption was as-

sessed using multivariate adjusted odds ratios (95% con-

fidence interval): odds ratio of 1.067 (CI: 0.129 - 8.813),

0.975 (CI: 0.057 - 3.061) and 2.694 (CI: 0.536 - 13.544)

for Preeclampsia, Apgar 1’ < 7, and birth weight ≥ 3800

g respectively. This means that a history of hypertension

in the family multiplies by three the risk of having an

infant ≥ 3800 g in alcohol drinkers.

Table 2. Risk factors for GDM according to alcohol status.

Overall

oup

(n =

240)

Abstainers (n = 162)Drinkers (n = 78) p values

Maternal age ≥ 35 years 64 (26.7%) 42 (25.9%) 22 (34.4%) 0.139

History of diabetes in the family 79 (32.9%) 51 (31.5%) 28 (35.9%) 0.594

History of HTA in the family 19 (7.9%) 8 (4.9%) 11 (14%) 0.026

History of Macrosomia 31 (12.9%) 22 (13.6%) 9 (12%) 0.803

History of stillbirth 15 (6.3%) 13 (8%) 2 (3%) 0.182

History of polyhydramnios 4 (1.7%) 3 (1.9%) 1 (1.5%)

0.844

History of congenital malformation 0 0 0

BMI > 25 kg/m2 91 (37.9%) 58 (35.8%) 5 (6%) 0.406

Table 3. Mother/infant’s adverse outcomes according to GDM status (N = 221).

Preeclampsia GDM (n = 20) 2 (10%) Non GDM (n = 201) 17 (8.5%) p values 0.814

Cesarean section 9 (45%) 55 (27.4%) 0.097

Apgar score 1’ < 7 3 (15%) 6 (3%) 0.038

Birthweight < 2500 gr 1 (5%) 10 (4.9%) 0.657

Birthweight ≥ 3800 gr 2 (10%) 16 (7.9%) 0.502

Shoulder dystocia or 0 0 -

other birth injury

Neonatal hypoglycemia 0 0 -

FAS 0 0 -

T.-U. Barthélémy et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 208-212 211

Table 4. GDM diagnosis and mother/infant’s adverse outcomes according to alcohol status (N = 221).

Alcohol drinkers (n = 71) Alcohol abstainers (n = 150) p values

GDM 7 (9.9%) 13 (8.7%) 0.773

Preeclampsia 6 (8.5%) 13 (8.7%) 0.957

Cesarean section 23 (32.4%) 41 (27.3%) 0.439

Apgar score 1’ < 7 4 (5.6%) 5 (3.3%) 0.419

Birthweight < 2500 g 2 (2.8%) 9 (6%) 0.310

Birthweight ≥ 3800 g 10 (14.1%) 8 (5.3%) 0.0284

4. COMMENTS

When compared to the prevalence found five years ago

(5.2%) in a multicentre study in Kinshasa [7] the rate of

this one-hospital-based study (9%) is much higher,

probably due to differences in study population sampling,

but a real rise should be questioned. Nevertheless, it is

expected to rise with use of lower blood glucose stan-

dards recently recommended by the 6th Symposium on

Pregnancy & Diabetes held in Salzburg, Austria, in

March 2011, which emphasized the HAPO study [8] and

seems to have got global agreement on the “one-step

diagnosis” of gestational diabetes mellitus (GDM). This

makes GDM range among epidemic problems to be fa-

ced in our milieu, not only for pregnancy outcomes but

mostly for prevention strategies, since GDM is likely to

announce type 2 diabetes.

In respect of alcohol consumption during pregnancy, it

is known that South Africa has the highest rate of FAS in

the world [9], but data from other African countries are

scarce to find. The rate of drinkers among pregnant wo-

men of our series (32.5%) is much higher than that of

4.4% reported in an Indian series [10]) and in North

America (10% in USA and 17% - 25% in Canada [11]).

Rates reported in Europe vary considerably from 34% in

France [12] to 81% in Ireland [13]. Due to feeling of

guilt or shame likely to accompany self-reporting of al-

cohol consumption by pregnant women [14], the actual

rate of our study might have to be higher.

Side effects related to alcohol consumption have been

reportedly noticeable even with light drinking, which led

to the “no alcohol at all during pregnancy” recommen-

dation [15,16]. Since most consumers of our series were

heavy ones, many fetuses were expected to be at risk.

Literature related to influences of alcohol consumption

on pregnancy generally refers to evaluation of consump-

tion during the first half of pregnancy [1-5]. Our study

deals with the second half but we have supposed that

drinking habits might be similar months before. This

supposition is supported by the fact that the most in-

voked reason for alcohol consumption was the preven-

tion of discomforting nausea and vomiting.

Lack of FAS in our series could thus be linked to fail-

ure to diagnose this condition in newborns, or to a lesser

sensibility of fetuses of our milieu, which remains to be

addressed. Mullally et al. [13] also observed only 3

cases (0.005%) of FAS among women whose up to 81%

were alcohol consumers.

As of GDM related mother/infant’s adverse outcomes

lack of significant differences between GDM and non

GDM women (except for Apgar score < 7 at the first

minute) could be attributed to huge follow-up of GDM

women while results remained blinded for others. This

finding is consistent with the need to actively treat GDM

in order to improve mother-infant’s outcomes. Increased

risk of Birth weight ≥ 3800 g by alcohol consumption

mostly among women having familial history of HTA is

difficult to interpret. Previously, protective effects of

moderate drinking on the development of type 2 diabetes

in elders has been evidenced mostly when compared

with heavy drinkers but not with abstainers [17]. No

favorable alcohol effect however has been claimed either

on GDM detection or survey or on APO in diabetic pa-

tients although it has been suggested that moderate

drinking would be associated with increased insulin sen-

sitivity [6].

5. CONCLUSIONS

The prevalence of alcohol consumption by pregnant

women in our milieu is as high as 32.5%, most of them

being heavy drinkers. The prevalence of GDM (9%)

seems not to be impacted by alcohol consumption. As of

mother/infant’s adverse outcomes (including FAS) lack

of significant differences between GDM and non GDM

(except for Apgar score < 7 at the first minute) is con-

sistent with the need to actively treat GDM. Influence of

alcohol consumption on Birth weight ≥ 3800 g mostly in

setting of familial history of HTA remains to be ad-

dressed.

T.-U. Barthélémy et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 208-212

212

6. ACKNOWLEDGEMENTS

We are grateful to colleagues and collaborators from the department of

OB-GYN, University Clinics, Kinshasa, DR Congo for invaluable assi-

stance in collecting data and caring for pregnant women.

REFERENCES

[1] Hanson, J.W., Streissguth, A.P. and Smith, D.W. (1978)

The effects of moderate alcohol consumption during pre-

gnancy on fetal growth and morphogenesis. Journal of

Pediatrics, 92, 457-460.

doi:10.1016/S0022-3476(78)80449-1

[2] Little, R.E. (1990) Moderate alcohol use during preg-

nancy and decreased infant birth weight. Pedi atrics, 85,

1-9.

[3] Ebrahim, S.H., Anderson, A.L. and Floyd, R.L. (1999)

Alcohol consumption by reproductive-aged women in

the USA: An update on assessment, burden and preven-

tion in the 1990s. Prenatal and Neonatal Medicine, 4,

419-430.

[4] Mukherjee, R.A.S., S. Hollins, M.T. and Abou-Saleh, J.T.

(2005) Low level alcohol consumption and the fetus.

British Medical Journal, 330, 375-376.

doi:10.1136/bmj.330.7488.375

[5] Strandberg-Larsen, K., Nielsen, N.R., Grønbaek, M.,

Andersen, P.K., Olsen, J. and Andersen, A.M. (2008)

Binge drinking in pregnancy and risk of fetal death. Ob-

stetrics and Gynecology, 111, 602-609.

doi:10.1097/AOG.0b013e3181661431

[6] Joosten, M.M., Chiuve, S.E., Mukamal, K.J., Hu, F.B.,

Hendriks, H.F. and Rimm, E.B. (2011) Changes in alco-

hol consumption and subsequent risk of type 2 diabetes

in men. Diabetes, 60, 74-79. doi:10.2337/db10-1052

[7] Tandu-Umba, N.F.B., Paka M.A., Mbungu, M.R. and

Muls, E. (2009) Détermination de la prévalence du dia-

bète gestationnel et des facteurs associés à Kinshasa. An-

nales Africaines de Médecine, 3, 321-325.

[8] The HAPO Study Cooperative Research Group (2008)

Hyperglycemia and Adverse Pregnancy Outcomes. The

New England Journal of Medicine, 358, 1991-2002.

doi:10.1056/NEJMoa0707943

[9] O’Connor, M.J., Tomlinson, M., LeRoux, I.M., Stewart,

J., Greco, E. and Rotheram-Borus, M.J. (2011) Predictors

of alcohol use prior to pregnancy recognition among

township women in Cape Town, South Africa. Social

Sciences and Medicine, 72, 83-90.

doi:10.1016/j.socscimed.2010.09.049

[10] Potukuchi, P.S. and Rao, P.G. (2010) Problem alcohol

drinking in rural women of Telangana region, Andhra

Pradesh. Indian Journal of Psychiatry, 52, 339-343.

doi:10.4103/0019-5545.74309

[11] Centers for Disease Control and Prevention (2004) Al-

cohol consumption among women who are pregnant or

might become pregnant-United States, 2002. Morbidity

and Mortality Weekly Reports, 53, 1178-1181.

[12] Chassevent-Pajot, A., Guillou-Landréat, M., Grall-Bronnec,

M., Wainstein, L., Philippe, H.J., Lombrail, P. and Vé-

nisse, J.L. (2011) Étude de prévalence des conduites ad-

dictives chez les femmes enceintes dans une maternité

universitaire. Journal de Gynécologie, Obstétrique et

Biologie de la Reproduction, 40, 237-245.

[13] Mullally, A., Cleary, B.J., Barry J., Fahey, T.P. and Mur-

phy, D.J. (2011) Prevalence, predictors and perinatal out-

comes of peri-conceptional alcohol exposure—retros-

pective cohort study in an urban obstetric population in

Ireland. BMC Pregnancy Childbirth, 11, 11-27.

doi:10.1186/1471-2393-11-27

[14] King, J.C. (1997) Substance abuse in pregnancy: A big-

ger problem than you think. Postgraduate Medicine, 102,

135-150. doi:10.3810/pgm.1997.09.313

[15] Jacobson, J. and Jacobson, S. (1999) Drinking moder-

ately and pregnancy effects on child development. Alco-

hol Research and Health, 23, 25-30.

[16] Carson, G., Cox, L.V., Crane, J., Croteau, P., Graves, L.,

Kluka, S., Koren, G., Martel, M.J., Midmer, D., Nulman,

I., Poole, N., Senikas, V. and Wood, R. (2010) Society of

obstetricians and gynaecologists of canada. Alcohol use

and pregnancy consensus clinical guidelines. Journal of

Obstetrics and Gynaecology of Canada, 32, S1-S31.

[17] Liu, C., Yu, Z., Li, H., Wang, J., Sun, L., Qi, Q. and Lin,

X. (2010) Associations of alcohol consumption with dia-

betes mellitus and impaired fasting glycemia among

middle-aged and elderly Chinese. BMC Public Health,

10, 713-728. doi:10.1186/1471-2458-10-713