Effect of maternal perceived stress during pregnancy on gestational diabetes mellitus risk: A prospective case-control study

https://doi.org/10.1016/j.dsx.2020.06.048Get rights and content

Highlights OF STUDY

  • In this hospital-based case-control study, we show high perceived stress as a potential determinant of GDM.

  • We also note the absence of correlation between stress scores and maternal blood glucose values.

Abstract

Background and aims

A variety of risk factors have been reported for the development of gestational diabetes mellitus (GDM). But limited review on the role of antenatal perceived stress necessitated the design of the present study to evaluate the association between GDM and perceived stress during pregnancy.

Methods

A prospective case-control study was carried out among 100 GDM cases and 273 matched controls, attending regular antenatal clinic at two private hospitals of Karnataka. Data was collected by personal interviews using a standard questionnaire. Perceived stress was assessed using the Cohen 10-item Perceived Stress Scale. Score of ≥20 was identified as high stress. Statistical Package for the Social Sciences version 15 was used for analysis.

Results

Exposure rates for high maternal perceived stress among cases during pregnancy were noted. The odds of GDM were 13 folds higher among those with high antenatal stress (≥20) compared to those with low (<20) (p < 0.001) perceived stress. No correlation between maternal antenatal stress and blood glucose following OGTT was noted.

Conclusions

The study identified high perceived stress during pregnancy as a potential risk factor for GDM.

Introduction

Gestational diabetes mellitus (GDM) is defined as the diabetes diagnosed in second and third trimesters of pregnancy [1]. With time, the disease has emerged as a global public health problem [2]. According to International Diabetes Federation (IDF) 2019 Diabetes Atlas, GDM continues to affect one in six births worldwide [3]. It estimates 20.4 million global live births (15.8%) are to women with hyperglycaemia in pregnancy [3]. Among them, 83.6% of adverse perinatal outcomes are still due to GDM, 7.9% are caused by pre-GDM. Remaining 8.5% are due to other diabetes sub-types first diagnosed during pregnancy [3]. In India alone, the disease is complicating nearly four million pregnancies annually, representing large subset of population at high-risk for adverse perinatal morbidity and mortality if addressed inappropriately [2]. Beyond perinatal implications, GDM marks the beginning of a vicious cycle in which diabetes begets more diabetes [4,5], leaving a legacy for both affected mother and her offspring to face impending long-term consequences [6].

Besides diet and other modifiable risk factors, psychological maternal stress has the potential to exacerbate GDM risk independently [[7], [8], [9]]. The stress of any form stimulates gluconeogenesis by activating hypothalamic–pituitary–adrenal (HPA) axis that mediates production of glucocorticoid and corticotrophin releasing hormones, leading to subsequent hyperglycaemia. This mechanism of stress induced hyperglycaemia, along with reduced insulin sensitivity, intends to supply terminal energy for the urgent needed ‘fight or flight’ response. However, in addition to unhealthy hyperglycaemia, this process is also associated with low-grade chronic inflammation that eventually causes more harm than does benefit to the intra-uterine life. The stress of any form also influences intra-uterine pro-inflammatory milieu during pregnancy [[7], [8], [9]]. Partly mediated through maternally-derived cytokines, placental inflammation [10,11] or modulation of nutrient transfer to foetus, the stress is capable of programming foetus towards its long-term susceptibility to develop chronic diseases later in life [11,12]. In other words, overall dysregulated maternal inflammation due to stress is one of the established key mediators for influencing GDM-related adverse outcomes during pregnancy [11,13].

Given the high prevalence of both GDM [14] and psychological stress [15] among Indian women of childbearing years, their co-occurrence during pregnancy is more likely. Pregnancy, by virtue of its inherent emotional component, is a potentially stressful event [16]. While adjusting to the felt-sense of this phase, if a woman develops an additional medical condition as glucose intolerance during her pregnancy, the toll of her psychological stress is expected to be even higher [[17], [18], [19], [20]]. Despite this, the current national guidelines for GDM care do not address the issue of antenatal stress management [21,22]. Moreover, very few studies have studied dose-dependent relationship between perceived stress during pregnancy and GDM risk [23,24]. This additional investigation is necessary to identify threshold for perceived stress in order to provide adequate recommendations on GDM risk reduction among Indian women.

Due to paucity of knowledge regarding the level of antenatal perceived stress among south Indian women and their dose-dependent relationship with GDM risk, the present prospective case-control study was designed to identify the association between maternal perceived stress during pregnancy and GDM risk. In addition, the study also aimed to determine the correlation between antenatal perceived stress and maternal blood glucose levels following diagnostic oral glucose tolerance test (OGTT). The author’s hypothesis was to explore the association between antenatal perceived stress and GDM risk, and the correlation between stress scores and absolute maternal blood glucose values during OGTT.

Section snippets

Study design and participants

The present hospital-based prospective case-control study was carried out at two private hospitals of a coastal district situated along the western coastline of southern India. The detailed description regarding study setting, recruitment of study subjects, operational definitions of cases and controls, data collection methodology, and assessment of physical activity have been published previously [25,26]. Sample size was calculated considering high-perceived stress as a risk factor for GDM.

Maternal antepartum perceived stress and gestational diabetes mellitus risk

The distribution of recruited study subjects as per the diagnostic criteria and their baseline socio-demographic characteristics have been described previously [24,25]. Results showed more than half of the cases (53.0%) have been experiencing high antenatal stress whereas over 90% of the controls feeling low stress during their pregnancy. The odds of GDM were 13 folds higher among those scored high antenatal stress compared to those scored low (OR: 12.9; 95% CI: 7.2–23.1; p < 0.001) [24,25].

Stratified Analysis

As

Discussion

A prospective case-control design to identify hitherto unexplored risk factors for GDM, like perceived stress during antenatal period, was novel in comparison to previous literature. The present study identified high perceived stress during pregnancy as a potential determinant of GDM among antenatal women of southern coastal India. However, there was poor or no correlation between stress scores and maternal blood glucose values following diagnostic OGTT.

In 2014, Silveira et al. carried out a

Conclusions

Despite existence of poor or no correlation with maternal blood glucose levels, high perceived stress during pregnancy was identified as a potential risk factor for GDM. It is, thus, advisable that pregnant women should undergo evaluation for stress and be counselled for stress management techniques during pregnancy.

Limitations of the study

Cohen PSS was not designed as a diagnostic tool for perceived stress and, therefore, have no established cut-points for high/low stress. Though participants were informed to report their perceived stress over the past one month, recall bias cannot be ruled out. Hospital-based data collection limits generalization of the study findings, but community-based identification of GDM cases was also a difficult task due to varying time periods of diagnosis, multitude of tests, and varying modifications

Disclaimer

The views expressed in the submitted article belong to the authors and not an official position of the institution. The manuscript has been read and approved by all the authors. The requirements for authorship have been met, and each author believes that the manuscript represents honest work.

Source of support

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Presentation at a meeting

The abstract was submitted to “13th SEA Regional Meeting of The IEA Jointed with International Conference of Public Health and Sustainable Development” to be held in October 2018, but the paper was not presented in the conference. The submitted abstract is available online at the conference website: http://conference.fkm.unand.ac.id/index.php/ieasea13/IEA/paper/view/674

Authors’s contribution

Dr. Surabhi Mishra: conceived the idea, reviewed literature, prepared and wrote the original draft.

Dr. Avinash Shetty: conceptualize the idea, supervised, reviewed, edited, and finalized the writing.

Dr. Chythra R Rao: assisted in data analysis, supervised, reviewed, edited, and finalized the writing.

Dr. Sathisha Nayak: assisted in data collection, supervised, reviewed, edited, and finalized the writing.

Dr. Asha Kamath: assisted in data analysis, reviewed, edited, and finalized the writing.

Declaration of competing interest

Nil.

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      Research has shown an independent dose-response association between stress and risk of abnormal glucose metabolism in women (Williams et al., 2013). While type-2 diabetes is associated with stress, particularly among lower socio-economic status (SES) groups (Abraham et al., 2007), stress has only recently been examined for its association with GDM (Hosler et al., 2011; Mishra et al., 2020; Silviera et al., 2014). Racial discrimination is an important source of stress for racial/ethnic minority and foreign-born groups and may impact risk of GDM.

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