ASSESSMENT OF GESTATIONAL DIABETES MELLITUS RELATED STRESS USING A SPECIFIC SCALE ADMINISTERED AS AN ONLINE MOBILE APPLICATION

Objective: Aim of the study was to assess the Gestational Diabetes Mellitus (GDM) related stress among pregnant women using an online mobile application based specific stress scale for GDM. 
Methods: This was a prospective observational study. All GDM patients who have used the Gestational Diabetes Stress Scale (GDSS)-mobile application within the study period were included (176 patients). Their total and subscale stress scores were analyzed. 
Results: This study found that 52.84% of the total population needed clinical attention for GDM related stress. The subscale scores revealed that 65.91% of the population needed clinical attention for emotional burden, 15.34% of the population needed clinical attention for medication-related stress, 69.89% of the population needed clinical attention for social or economical stress and 36.36% of the population needed clinical attention for health care set up related stress. 
Conclusion: Based upon this study we conclude that GDSS is a good invention. There existed a gap in measuring GDM related stress in pregnant women and GDSS is a solution for the same.


INTRODUCTION
Gestational Diabetes Mellitus (GDM) is a condition of any degree of glucose intolerance with onset or first detected during pregnancy. Prevalence of GDM increasing worldwide (21 million new cases per year) [1]. According to International diabetes federation, 16% of the children born alive in 2013 had complications due to hyperglycemia. Goals for Glycemic Control in Pregnancy are like, Fasting 60-90 mg/dl, Pre meal<100 mg/dl, 1 hr postprandial<140 mg/dl, 2 h postprandial<120 mg/dl, Bedtime<120 mg/dl, and 2:00-6:00 A. M. 60-90 mg/dl [2]. GDM can cause complications in both mother and foetus. Major Fetal complications are Macrosomia, spontaneous abortion, congenital malformation and intrauterine death and maternal complications and risk of diabetes recurrence in future pregnancies, the future possibility of diabetes mellitus, polyhydramnios, pregnancy toxemia, urinary tract infection, candidiasis, higher incidence of premature childbirth and caesarean delivery [3]. Studies found that prevalence of diabetes is high among females [4] and GDM can further increase the risk for the same.
GDM will increase emotional disequilibrium during pregnancy. It is well documented that pregnancy is linked with unique psychological stress and diabetes also linked with significant distress. In addition to the stress of pregnancy, GDM is also a stress factor [5][6][7]. Women with GDM also experience shock, fear and stress [8,9]. Maternal stress during pregnancy can cause emotional or cognitive problems in childlike attention-deficit/hyperactivity, anxiety and language delay [10].
Stress can affect GDM control by influencing proper diet compliance, medication adherence or glucose monitoring. To prepare a suitable plan for GDM related stress proper identification of the stress level along with the possible sources for the same is needed. Manikandan et al. in Tamilnadu concluded from their study that providing proper patient counseling services and creating awareness regarding the condition can improve patient's medication adherence [11].
Primary objective of the study was to assess the GDM related stress in pregnant women through the administration of an online mobile application based specific scale for gestational diabetes mellitus.

Study Design:
This was a prospective observational study.

Study duration: Six months
Study population: 176 pregnant women with GDM Data collection: Data collection was done through GDSS mobile application.

Study criteria
All pregnant women with GDM irrespective of gestational weeks, naturally pregnant women and In vitro fertilization (IVF) pregnant women with GDM were included in the study. Non-consenters and incomplete data entries were excluded from the study.

Materials used
A mobile application called 'GESTATIONAL DIABETES STRESS SCALE'. It is available in Google play store (https://play.google.com/ store/apps/details?id=com.byzero.gdss)

Age wise distribution
Among the total study population majority of the patients were from 24 to 29.12 y which is 44.88% of the population, followed by 30 to 34.12years (25%), 18 to 23.12years (16.48) and the least were from the age group of greater than or equal to 30 y (13.67%).

Educational status
Most of the patients in the study population were graduate which is 43.75% of the study population followed by postgraduate (21.59%), metric (18.18%), higher secondary (12.05%) and less number of the population was illiterate (3.98%). bank sectors, 3.40% were from government sectors and 20.45% were from other categories.

Monthly family income
Majority of the study population (40.04%) were from less than or equal to 10,000Rs, followed by 10000 to less than or equal to 20000 (32.96%), 20000 to less than or equal to 30000 (11.93%), greater than or equal to 40000 (10.22%) and the least was from 30000 to less than or equal to 40000 (4.54%).

Month of pregnancy
Highest number of population 118 (67.04%) of the study population were in the third trimester during the study period, 41 (23.30%) of the population were in the second trimester and the least of the population, 17 (9.66%) were in the first trimester.

Pregnancy sequence
Majority of the population were conceiving for the first time which is 50.56%, followed by second time 39.77%, fourth time (3.40%), fifth time (2.27%), 1.70% of the population were conceiving for the sixth or seventh time and one patient was conceiving for the eighth time.

History of GDM in last pregnancy
Among total study population 87 patients were conceiving for more than one time and among that 30 patients had a history of GDM in their last pregnancy which is 34.49% of the study population and 57 patients did not have a history of GDM in their last pregnancy.

Family history
Among the study population, 97 patients in the study population had a family history of diabetes which is 55.11% of the population.

GDM management
Majority of the patients needed only diet and lifestyle modifications which is 53.98%. 25.57% of the study population was on insulin, 14.20% patients were on oral hypoglycemic agents and least part of the population 6.25% were on both insulin and OHA.

GDM will disappear after delivery or not
The question was 'GDM will disappear after delivery. Do you agree?'. A good proportion of the population of 109 (61.13%) patients believed GDM will disappear after delivery. 15 (8.52%) patients thought GDM will not disappear after delivery and 52(29.55%) patients replied 'don't know' to the question.

Risk of an unborn child
'Unborn child is at risk if the mother is untreated. Do you agree?' This was the fourth question and the highest number of population 127 (72.16%) responded like an unborn child is at risk if the mother is untreated. 16(9.06%) patients felt unborn child is not at risk if the mother is untreated and 33(18.75%) patients response was they don't know the answer.

Risk for future type 2 diabetes
The question asked was 'women with GDM are at an increased risk of future type 2 diabetes. Do you agree? Patient responses were noted. The given statement was agreed by 98(55.69%) patients and 23(13.06%) of patients felt women with GDM are not at an increased risk of future type 2 diabetes and 55(31.25%) patients response was they don't know the answer.

Risk factors of GDM
The patients were given five options for the question of what are the risk factors for GDM. The patient response was as follows: Table 2 shows, patients had a choice to choose more than one option. 112 patients believed the family history of diabetes is the risk for GDM, 94 patients thought pre-pregnancy obesity as the risk factor, 83 patients thought GDM in last pregnancy as the risk factor, 76 patients thought any or all of these options are the risk factors and 46 patients were didn't know what are the risk factors for GDM

Management of GDM
The question was 'What are the treatment options for GDM?' Three options along with all of the above and don't know were given and the patient responses were noted. For this question, the patient selected more than one option. 141 patients thought lifestyle modification was the management option for GDM, 92 patients thought oral hypoglycemic agents, 80 patients thought insulin injection, 72 patients selected all of the above and 20 patients selected they don't know the answer.

Gestational diabetes-related to stress
Gestational Diabetes Stress Scale (GDSS) was used to detect the stress levels in pregnant women. This is a 16 item scale which gives the total score to monitor the overall stress level and four subscale score to detect the type of distress.

Total GDSS score
Total GDSS score gives an overall stress level in patients. Whether the patient needed clinical attention or not could be detected using total GDSS score. Among the study population, 52.84% of the study population needed clinical attention and 47.16% of the population did not need clinical attention.

Medication-related stress
This is the second subscale in GDSS, which include 3 items. Patients only on lifestyle modification were not monitored for medicationrelated stress. The 3 items included in this subscale are related to medication. Which are like 'Taking insulin for GDM is painful', 'Every time when I take insulin or oral anti-diabetic agents I feel bad' and 'I feel that I am taking too much of medications'. Among the 81 patients who were on medication for GDM, 38.2% of the study populations needed clinical attention and 61.7% of the study populations did not need clinical attention.

Social or economical stress
This is the third subscale of the GDSS which include 3 items. The three items included in this subscale are 'I spend more money than what I estimated because of GDM', 'I don't get enough support from my family and friends' and 'I am not able to be normal because of various restrictions due to GDM.'. 69.89% of the populations needed clinical attention for social or economical stress and 30.11% of the populations did not need clinical attention for the same.  No specific stress scale was available to monitor stress level in pregnant women with GDM before the introduction of GDSS. However, there are studies conducted to detect GDM related stress in pregnant women using more than one stress scales. Lydon k et al. conducted a similar study. They investigated the psychological stress associated with diabetes during pregnancy (a pilot study). Examined the psychosocial profile of 25 women with gestational diabetes mellitus and compared them to 25 non-diabetic pregnant women. They used the pregnancy experience scale (PES), the depression, anxiety stress scale (DASS), the problem areas in diabetes scale  and Perceived social support scale (PSSS). The GDM group reported a significantly greater ratio of pregnancy 'hassles' to pregnancy 'uplifts'. The GDM groups also had a significantly higher depression score and were twice as likely to score above the cut-off for possible depression. Elevated levels of diabetes-related distress were found in 40% of women with GDM. In addition, the GDM group reported less social support from outside family. Thus the study indicates the need of psychological screening in GDM and the provision of psychological support in some cases.
Limitations of this work were that it was conducted among women who knew how to use a mobile application and also among women who could understand English. We cannot check the GDM related stress among Illiterate women.

CONCLUSION
This study indicated 52.84% of the total population needed clinical attention for GDM related stress which is a significant amount and proper precaution must be given to stress management while preparing an action plan for GDM management. Analyzing subscale score reveals 65.91% of the population needed clinical attention for the emotional burden,it indicates the patient's need for an emotional support, 69.89% of the population needed clinical attention for social or economic stress, 15.34% of the population needed clinical attention for medication-related stress and 36.36% of the population needed clinical attention for health care set up related stress. Comparing data of the stress level and awareness monitoring clearly indicates that there is a lack of proper awareness among GDM patients and they need clarity about the medical condition, management options, drugs etc. Lack of proper awareness itself can increase the stress level in patients. Pharmacists can solve this issue by providing proper awareness through proper patient counseling services.

AUTHORS CONTRIBUTIONS
All the authors have contributed equally

CONFLICT OF INTERESTS
Declared none