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National Journal of Physiology, Pharmacy and Pharmacology  724
2017 | Vol 7 | Issue 7
ABSTRACT
Background: Gestational diabetes affects the health of the women, the fetus, and even after birth, the baby or child.
Studies related to the assessment of the effects of yoga and pranayama on metabolic parameters, maternal and fetal
outcome among gestational diabetic patients are inadequate. Aim and Objectives: The aim of the present study was to
assess the effects of yoga and pranayama on metabolic parameters, maternal and fetal outcome in gestational diabetes.
Materials and Methods: A total of 162 gestational diabetic patients were recruited in the study; after removing the drop
outs, 75 of them did specific yoga and pranayama (test group) for 3 months and the remaining, blood sugar-matched,
76 patients were recruited as (control group) who were not on any yoga practice. The data obtained were analyzed
using appropriate statistical methods such as mean, standard deviation, and t-test for paired data and categorical data
were analyzed using Chi-square test (r × c table). P value was considered significant below 0.05. Results: Analysis of
data showed statistically significant difference between metabolic parameters, maternal and fetal outcome of mothers
with gestational diabetes mellitus (GDM) between yoga group and control group P  0.01. Conclusion: Yoga and
pranayama significantly decrease blood glucose level which in turn can prevent adverse maternal and fetal outcomes
of GDM. Safety during pregnancy is paramount and exercises such as low exerting forces such as yoga can be safe for
both mother and fetus.
KEY WORDS: Gestational Diabetes; Yoga Asanas; Pranayama; Maternal and Fetal Outcome
INTRODUCTION
Gestational diabetes mellitus (GDM) can be defined as
the abnormal carbohydrate tolerance with the onset or first
detection during the present pregnancy at 24-28 weeks of
gestation. The prevalence of GDM in India varies from 3.8%
to 21% in different parts of the country, depending on the
geographical locations and diagnostic methods used.[1,2]
GDM
Access this article online
Website: www.njppp.com Quick Response code
DOI: 10.5455/njppp.2017.7.0306713032017
National Journal of Physiology, Pharmacy and Pharmacology Online 2017. © 2017 Balaji P A and Smitha R V Varne. This is an Open Access article distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or
format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
has been found to be more prevalent in urban areas than in
rural areas. Nearly 50% of women with GDM will develop
type 2 diabetes mellitus over a period of 5-20 years. Chances
of having diabetes in children are about 6% when the father
is diabetic, it raises to 20% if both the parents are diabetic.[2,3]
GDM affects the health of the women, the fetus, and even
after birth, the baby or child. Hyperglycemic placental
environments increase the risk of traumatic pregnancies
influenced by macrosomia (larger than usual birth weight).
This in turn increases the risk of the baby having shoulder
damage during birth. Macrosomia can be further exacerbated
by excess levels of insulin circulating in the placenta. This is
due to the increased growth effects of insulin on the fetus.[4-7]
All the above facts strongly indicate for timely action for
screening all pregnant women for glucose intolerance,
National Journal of Physiology, Pharmacy and Pharmacology
RESEARCH ARTICLE
Physiological effects of yoga asanas and pranayama on metabolic
parameters, maternal, and fetal outcome in gestational diabetes
Balaji PA, Smitha R Varne
Department of Physiology, Dr. B. R. Ambedkar Medical College, Bengaluru, Karnataka, India
Correspondence to: Balaji P A, E-mail: drpaba@rediffmail.com
Received: March 01, 2017; Accepted: March 13, 2017
Balaji and Varne Effects of yoga and pranayama in gestational diabetes
725 National Journal of Physiology, Pharmacy and Pharmacology 2017 | Vol 7 | Issue 7
achieving euglycemia in them, and ensuring adequate
nutrition may prevent in all probability, the vicious cycle
of transmitting glucose intolerance from one generation to
another. The management of GDM should aim to reduce
the effects of hyperglycemia by controlling blood glucose
levels. Along with pharmacology and dietary interventions,
exercise has a powerful potential to assist with blood glucose
control. Due to the uncertainty of risks and benefits of
exercise during pregnancy, women tend to avoid exercise.[8]
The ancient Indian science of yoga is a way of life which
includes changes in mental attitude, diet, and practice
of specific techniques such as yoga postures (asanas),
breathing practices (pranayamas), and meditation.[9]
To
treat GDM naturally, the antenatal mother should practice
yoga, pranayama, relaxation, and meditation. It is the
best recommendation to women with GDM.[10]
There are
significant benefits of yoga and pranayama practices on
metabolic parameters and anthropometric measurements
in uncomplicated type 2 diabetic patients. Yogic exercises
cause the muscles to absorb the excess glucose in the blood,
thereby reducing the blood sugar level. They help the
pancreas and liver to function effectively, which regulates
the blood sugar levels. Asanas help in rejuvenating the
pancreatic cells, thereby assisting insulin secretion. The
muscular movements also help in bringing down the blood
sugar levels.[11]
Few studies have looked at the effects of yoga on maternal
and fetal/neonatal outcome variables. However, studies
related to assessment of the effects of yoga and pranayama
on metabolic parameters, maternal and fetal outcome among
gestational diabetic patients are still inadequate. Hence, the
present study was carried out to assess the effects of yoga
and pranayama on metabolic parameters, maternal and fetal
outcomes in gestational diabetes.
MATERIALS AND METHODS
The present prospective study was conducted from
January to December 2016 in Department of Physiology,
Dr. B. R. Ambedkar Medical College, Kadugondanahalli,
Bangalore and Sakaria Hospital and Yoga Centre,
Bangalore, India. Ethical Clearance was obtained from
the Institutional Ethics Committee, Dr. B. R. Ambedkar
Medical College, Kadugondana Halli, Bangalore, India
and consent was obtained from the participants and was
informed of their right to withdraw anytime during the
course of the study.
Study Protocol
Patients were involved based on the inclusion and exclusion
criteria, non-probability purposive sampling technique.
A total of 162 gestational diabetic patients were selected in
the age group of 25-35 years based on the WHO criteria
of diagnosis of gestational diabetes. Patients were matched
with regard to blood sugar levels at Sakaria Hospital,
Bangalore, India. Data on obstetrical information were
recorded.All the patients were instructed to continue routine
treatment which included counseling on diet and regular
monitoring of blood glucose level, insulin therapy based
on the blood glucose level, and regular dose of iron, folic
acid, and calcium tablets from 24th
week to till delivery.
They were instructed to follow-up the visits regularly in
the antenatal outpatient department. They were divided
into test group (who underwent yoga practice) and control
group (who did not undergo any yoga practice). The test
group consisting of 82 patients was on insulin therapy. The
test group was taught yoga and pranayama for 3 continuous
months (from 24 weeks of gestation onwards), 1 h every day
by yoga expert in the morning between 7.00-8.00 am and
8.00-9.00 am in two batches as per the time/batch chosen
by the patients. The control group involved 80 patients and
was also on insulin treatment and did not undergo any yoga
practice.
Protocol of yogic practices and pranayama used in the
present study:
1. Loosening exercises for 10 min, which included
loosening neck, loosening fingers, loosening wrist,
shoulder rotation, twisting, hand stretch breathing, hands
in and out breathing, ankle stretching.
2. Asanas for 20 min, which included a) standing - tadasana
and ardhakatichakrasana, b) sitting - vajrasana, titali
asana (purna and ardha), siddha yoni asana, c) supine -
savasana (left lateral position).
3. Deep relaxation technique for 5-7 min.
4. Pranayama for 15 min which included nadi shuddi, sitali,
sitakari, sadanta, bhramari pranayamas.
Drop Outs
During the study, out of 82 patients from yoga group, 7 of
them dropped out and out of 80 patients from control group,
4 of them withdrew from the study due to personal reasons.
Blood samples for fasting blood sugar (FBS), postprandial
blood sugar (PPBS), glycosylated hemoglobin (HbA1c), and
insulin requirement per day were estimated before the starting
and at the end of 3-month period. HbA1c was estimated by
Bio-Rad D-10TM
.
Inclusion criteria included those with a history of GDM
between 24 and 28 weeks of gestation. Exclusion criteria
involved those with polyhydramnios, multiple pregnancy,
pregnancy induced hypertension (PIH), complicated
pregnancy, cardiac problems, obesity. Sample size was
determined by considering the results of previously published
studies and taking standard normal variate of 0.84 for power
of 80% and standard normal variate of 1.96 at 5% type 1 error.
Balaji and Varne Effects of yoga and pranayama in gestational diabetes
National Journal of Physiology, Pharmacy and Pharmacology  726
2017 | Vol 7 | Issue 7
Statistics
The data obtained were analyzed using MedCalc Statistical
Software version 12.7.8 (MedCalc Software bvba, Ostend,
Belgium; http://www.medcalc.org; 2014) and appropriate
statistical methods such as mean, SD and t-test for paired
data and categorical data were analyzed using Chi-square test
(r × c table). P value was considered statistically significant
below 0.05.
RESULTS
Tables 1-3 depicted very clearly that there is a significant
decrease in blood glucose level in yoga group compared
to control group and also the maternal and fetal outcome
parameters have significantly improved among yoga group
compared to control group.
DISCUSSION
In the present prospective study, 75 patients in yoga group
and 76 in control group showed statistically significant
difference between metabolic parameters and maternal
and fetal outcome of mothers with GDM between yoga
group and control group at P  0.01. Among yoga group,
the FBS improved from 132.44 to 100.06 with P  0.001
compared to control group which showed the improvement
from 133.45 to 111.23 with P  0.01. Similarly, the PPBS
among yoga group showed improvement from 150.33 to
121.56 with P  0.001. Concordantly in a study conducted
in Tamil Nadu, India, among yoga group, 24th
week
fasting blood glucose mean score was 122.99 mg/dl; after
intensive practice of yoga, the mean score at 28th
week was
106.31 mg/dl, 32nd
week was 102.37 mg/dl, and 36th
week
was 90.27 mg/dl and the post prandial blood glucose mean
score at 24th
week was 160.45 mg/dl and after yoga, the
mean score at 28th
week was 140.14 mg/dl, 32nd
week
was 127.01 mg/dl, and 36th
week was 117.13 mg/dl and
concluded that there was a significant reduction in the
fasting and postprandial blood glucose level in yoga group
than control group at P  0.001 level of significance.[12]
A
randomized controlled study conducted by Sununta found
that the intervention group showed significantly reduced
fasting plasma glucose, 2-h postprandial blood glucose,
and HbA1c in the intervention group with (P  0.05).[13]
In
another study which evaluated ten randomized controlled
trials indicated that yoga intervention presented with
lower incidences of prenatal disorders (P  0.05), and
small gestational age (P  0.05), lower levels of pain
and stress (P  0.05), and higher score of relationship
(P  0.05) and suggested that yoga is a safe and more
effective intervention during pregnancy.[14]
Narendran
et al. illustrated the effects of yoga in pregnant women,
who were matched to controls. Pregnant women practiced
yoga daily for 1 h, for 20-22 weeks, while the control
group walked twice daily for 30 min. The study showed
that in the group that practiced yoga, the incidence of
preterm labor was statistically lower (P  0.0006) and
birth weight was higher (P  0.01).[15]
Rakhshani et al.
showed that pregnant women who completed an 1 h yoga
classes, 3 times a week, from 12 to 28 weeks of gestation,
showed reduced rates of PIH, preeclampsia, gestational
diabetes, and intrauterine growth restriction (P = 0.018,
0.042, 0.049, 0.05 respectively).[16]
Field examined the
benefits of yoga and pregnant women who were clinically
depressed reporting that the yoga intervention group
had longer gestational age and increased birth weight as
compared to the control group receiving no yoga therapy.[17]
Table 1: Metabolic parameters in patients of test group
and control group
Parameters Test group (n=75) Control group (n=76)
At
24 weeks
After
36 weeks
At
24 weeks
After
36 weeks
FBS (mg/dl) 132.44 100.06** 133.45 111.23*
PPBS (mg/dl) 150.33 121.56** 152.11 128.99*
HbA1C 6.1±0.2 6.32±0.3 6.0±0.2 6.61±0.2
Requirement
of insulin/day
26.22±7.5 18.34±4.3** 28.44±4.8 20.14±6.4*
*P0.01, **P0.001. FBS: Fasting blood sugar, PPBS: Postprandial
blood sugar
Table 2: Comparison of maternal outcome of patients
with GDM between test and control group
Parameters Maternal
outcome
Test
group
n=75 (%)
Control
group
n=76 (%)
Weeks of
gestation (at
delivery)
37 13 (17.33) 42 (55.26)
37‑39 35 (46.66) 14 (18.42)
39‑42 25 (33.33) 19 (25)
above 42 2 (2.66) 1 (1.31)
Mode of
delivery
Normal 23 (30.66) 2 (2.63)
Normal with
episiotomy
28 (37.33) 3 (3.9)
Forceps 12 (16) 15 (19.73)
LSCS 12 (16) 56 (73.6)
Complications
during labor
Perianal injuries 4 (5.33) 23 (30.26)
Primary
postpartum
hemorrhage
2 (2.66) 4 (5.26)
Prolonged labor 9 (12) 26 (34.21)
No complications 60 (60) 23 (30.26)
Chi‑square: (1) 25.38, df=3, P0.00. (2) 66.6, df=3, P0.00.
(3) 38.79, df=3, P0.00. GDM: Gestational diabetes mellitus,
LSCS: Lower segment caesarean section
Balaji and Varne Effects of yoga and pranayama in gestational diabetes
727 National Journal of Physiology, Pharmacy and Pharmacology 2017 | Vol 7 | Issue 7
Another study by Martins and Pinto e Silva showed that
women with pregnancy-related lumbar and pelvic pain
had reduced pain after a 10 weeks yoga intervention (P 
0.0058). The pain level was measured by a visual analog
scale and by pain provocation tests.[18]
In the present study, among yoga group, the insulin
requirement per day reduced from 26.22 ± 7.5 to 18.34 ± 4.3
with P  0.001 compared to that among control group, the
reduction was from 28.44 ± 4.8 to 20.14 ± 6.4 with P  0.01.
We could not find studies to compare which addressed this
aspect of insulin requirement per day.
Limitations of the Present Study
(i) Larger sample study involving patients of different
geographical areas, ethnic background, religion, and
customs will be more informative, (ii) fetal outcomes such
as APGAR scoring, fetal anthropometry measurements were
not considered, (iii) trend of maternal anthropometry during
the study could not be analyzed, and (iv) studies including
gestational diabetic patients on metformin and patients on
insulin, both undergoing yoga and pranayama will be more
informative for planning proper management of gestational
diabetes.
CONCLUSION
Yoga and pranayama significantly decreases blood glucose
level which in turn can prevent adverse maternal and fetal
outcomes of GDM. Safety during pregnancy is paramount
and exercises such as low exerting forces such as yoga can be
safe for both mother and fetus.[19]
ACKNOWLEDGMENT
We are very thankful to all the mothers who took part in the
present study.
REFERENCES
1. Seshiah V, Balaji V, Balaji MS. Scope for prevention of
diabetes--’focus intrauterine milieu interieur’. J Assoc
Physicians India. 2008;56:109-13.
2. Seshiah V, Balaji V, Balaji MS, Paneerselvam A, Kapur A.
Pregnancy and diabetes scenario around the world: India. Int J
Gynaecol Obstet. 2009;104 Suppl 1:S35-8.
3. Anjalakshi C, Balaji V, Balaji MS, Ashalata S, Suganthi S,
Arthi T, et al. A single test procedure to diagnose gestational
diabetes mellitus. Acta Diabetol. 2009;46:51-4.
4. Coustan DR, Imarah J. Prophylactic insulin treatment of
gestational diabetes reduces the incidence of macrosomia,
operative delivery, and birth trauma. Am J Obstet Gynecol.
1984;150:836-42.
5. Hod M, Merlob P, Friedman S, Schoenfeld A, Ovadia J.
Gestational diabetes mellitus. A survey of perinatal
complications in the 1980s. Diabetes. 1991;40 Suppl 2:74-8.
6. Coustan DR. Pharmacological management of
gestational diabetes: An overview. Diabetes Care.
2007;30 Suppl 2:S206-8.
7. Coustan DR, Nelson C, Carpenter MW, Carr SR, Rotondo L,
Widness JA. Maternal age and screening for gestational
diabetes: A population-based study. Obstet Gynecol.
1989;73:557-61.
8. Padayachee C, Coombes JS. Exercise guidelines for gestational
diabetes mellitus. World J Diabetes. 2015;6:1033-44.
9. Taimini IK. The Science of Yoga. Madras, India: The
Theosophical Publishing House; 1965.
10. Narendran S, Nagarathna R, Nagendra HR.Yoga for Pregnancy.
London: Cassell Illustrated; 2008.
11. Balaji PA, Varne SR, Ali SS. Effects of yoga - Pranayama
practices on metabolic parameters and anthropometry in type 2
diabetes. Int Multidiscip Res J. 2011;1(10):1-4.
12. Abirami P, Raj J. Impact of yoga on blood glucose level among
mother with gestational diabetes mellitus at government
hospital, Tambaram, Chennai, Tamil Nadu. Indian J Health
Wellbeing. 2013;1(4):99-105.
13. Youngwanichsetha S, Phumdoung S, Ingkathawornwong T.
The effects of mindfulness eating and yoga exercise on blood
sugar levels of pregnant women with gestational diabetes
mellitus. Appl Nurs Res. 2014;27(4):227-30.
14. Jiang Q, Wu Z, Zhou L, Dunlop J, Chen P. Effects of yoga
intervention during pregnancy: A review for current status. Am
J Perinatol. 2015;32(6):503-14.
15. Narendran S, Nagarathna R, Narendran V, Gunasheela S,
Nagendra HR. Efficacy of yoga on pregnancy outcome.
J Altern Complement Med. 2005;11(2):237-44.
16. Rakhshani A, Nagarathna R, Mhaskar R, Mhaskar A,
Thomas A, Gunasheela S. The effects of yoga in prevention
Table 3: Comparison of fetal outcome and birth weight
of baby of patients with GDM between test and control
group
Parameters Fetal
outcome
Test
group (n=75)
Control
group (n=76)
Fetal
outcome
Congenital
malformation
2 (2.66) 4 (5.26)
Fetal
macrosomia
22 (29.33) 40 (52.6)
Intra uterine
growth
restriction
2 (2.66) 13 (17.10)
Intrauterine
fetal death
1 (1.33) 2 (2.63)
No
complications
48 (64) 17 (22.36)
Birth weight
of baby (kg)
2.5 5 (6.6) 16 (21.05)
2.5‑3.5 48 (64) 25 (32.89)
3.5 22 (29.33) 35 (46.05)
Chi‑square: (1) 29.07, df=4, P0.00. (2) 15.96, df=2, P0.01.
GDM: Gestational diabetes mellitus
Balaji and Varne Effects of yoga and pranayama in gestational diabetes
National Journal of Physiology, Pharmacy and Pharmacology  728
2017 | Vol 7 | Issue 7
of pregnancy complications in high-risk pregnancies:
A randomized controlled trial. Prev Med. 2012;55(4):333-40.
17. Field T, Diego M, Hernandez-Reif M, Medina L,
Delgado J, Hernandez A. Yoga and massage therapy reduce
prenatal depression and prematurity. J Bodyw Mov Ther.
2012;16(2):204-9.
18. Martins RF, Pinto e Silva JL. Treatment of pregnancy-
related lumbar and pelvic girdle pain by the yoga method:
A randomized controlled study. J Altern Complement Med.
2014;20(1):24-31.
19. Artal R, O’Toole M. Guidelines of the American College
How to cite this article: Balaji PA, Varne SR. Physiological
effects of yogasanas and pranayama on metabolic parameters,
maternal and fetal out come in gestational diabetes. Natl J
Physiol Pharm Pharmacol 2017;7(7):724-728.
Source of Support: Nil, Conflict of Interest: None declared.
of Obstetricians and Gynecologists for exercise during
pregnancy and the postpartum period. Br J Sports Med.
2003;37(1):6-12.

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Physiological effects of yoga asanas and pranayama on metabolic parameters, maternal, and fetal outcome in gestational diabetes, Dr Balaji pa, dr smitha r varne.pdf

  • 1. National Journal of Physiology, Pharmacy and Pharmacology 724 2017 | Vol 7 | Issue 7 ABSTRACT Background: Gestational diabetes affects the health of the women, the fetus, and even after birth, the baby or child. Studies related to the assessment of the effects of yoga and pranayama on metabolic parameters, maternal and fetal outcome among gestational diabetic patients are inadequate. Aim and Objectives: The aim of the present study was to assess the effects of yoga and pranayama on metabolic parameters, maternal and fetal outcome in gestational diabetes. Materials and Methods: A total of 162 gestational diabetic patients were recruited in the study; after removing the drop outs, 75 of them did specific yoga and pranayama (test group) for 3 months and the remaining, blood sugar-matched, 76 patients were recruited as (control group) who were not on any yoga practice. The data obtained were analyzed using appropriate statistical methods such as mean, standard deviation, and t-test for paired data and categorical data were analyzed using Chi-square test (r × c table). P value was considered significant below 0.05. Results: Analysis of data showed statistically significant difference between metabolic parameters, maternal and fetal outcome of mothers with gestational diabetes mellitus (GDM) between yoga group and control group P 0.01. Conclusion: Yoga and pranayama significantly decrease blood glucose level which in turn can prevent adverse maternal and fetal outcomes of GDM. Safety during pregnancy is paramount and exercises such as low exerting forces such as yoga can be safe for both mother and fetus. KEY WORDS: Gestational Diabetes; Yoga Asanas; Pranayama; Maternal and Fetal Outcome INTRODUCTION Gestational diabetes mellitus (GDM) can be defined as the abnormal carbohydrate tolerance with the onset or first detection during the present pregnancy at 24-28 weeks of gestation. The prevalence of GDM in India varies from 3.8% to 21% in different parts of the country, depending on the geographical locations and diagnostic methods used.[1,2] GDM Access this article online Website: www.njppp.com Quick Response code DOI: 10.5455/njppp.2017.7.0306713032017 National Journal of Physiology, Pharmacy and Pharmacology Online 2017. © 2017 Balaji P A and Smitha R V Varne. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. has been found to be more prevalent in urban areas than in rural areas. Nearly 50% of women with GDM will develop type 2 diabetes mellitus over a period of 5-20 years. Chances of having diabetes in children are about 6% when the father is diabetic, it raises to 20% if both the parents are diabetic.[2,3] GDM affects the health of the women, the fetus, and even after birth, the baby or child. Hyperglycemic placental environments increase the risk of traumatic pregnancies influenced by macrosomia (larger than usual birth weight). This in turn increases the risk of the baby having shoulder damage during birth. Macrosomia can be further exacerbated by excess levels of insulin circulating in the placenta. This is due to the increased growth effects of insulin on the fetus.[4-7] All the above facts strongly indicate for timely action for screening all pregnant women for glucose intolerance, National Journal of Physiology, Pharmacy and Pharmacology RESEARCH ARTICLE Physiological effects of yoga asanas and pranayama on metabolic parameters, maternal, and fetal outcome in gestational diabetes Balaji PA, Smitha R Varne Department of Physiology, Dr. B. R. Ambedkar Medical College, Bengaluru, Karnataka, India Correspondence to: Balaji P A, E-mail: drpaba@rediffmail.com Received: March 01, 2017; Accepted: March 13, 2017
  • 2. Balaji and Varne Effects of yoga and pranayama in gestational diabetes 725 National Journal of Physiology, Pharmacy and Pharmacology 2017 | Vol 7 | Issue 7 achieving euglycemia in them, and ensuring adequate nutrition may prevent in all probability, the vicious cycle of transmitting glucose intolerance from one generation to another. The management of GDM should aim to reduce the effects of hyperglycemia by controlling blood glucose levels. Along with pharmacology and dietary interventions, exercise has a powerful potential to assist with blood glucose control. Due to the uncertainty of risks and benefits of exercise during pregnancy, women tend to avoid exercise.[8] The ancient Indian science of yoga is a way of life which includes changes in mental attitude, diet, and practice of specific techniques such as yoga postures (asanas), breathing practices (pranayamas), and meditation.[9] To treat GDM naturally, the antenatal mother should practice yoga, pranayama, relaxation, and meditation. It is the best recommendation to women with GDM.[10] There are significant benefits of yoga and pranayama practices on metabolic parameters and anthropometric measurements in uncomplicated type 2 diabetic patients. Yogic exercises cause the muscles to absorb the excess glucose in the blood, thereby reducing the blood sugar level. They help the pancreas and liver to function effectively, which regulates the blood sugar levels. Asanas help in rejuvenating the pancreatic cells, thereby assisting insulin secretion. The muscular movements also help in bringing down the blood sugar levels.[11] Few studies have looked at the effects of yoga on maternal and fetal/neonatal outcome variables. However, studies related to assessment of the effects of yoga and pranayama on metabolic parameters, maternal and fetal outcome among gestational diabetic patients are still inadequate. Hence, the present study was carried out to assess the effects of yoga and pranayama on metabolic parameters, maternal and fetal outcomes in gestational diabetes. MATERIALS AND METHODS The present prospective study was conducted from January to December 2016 in Department of Physiology, Dr. B. R. Ambedkar Medical College, Kadugondanahalli, Bangalore and Sakaria Hospital and Yoga Centre, Bangalore, India. Ethical Clearance was obtained from the Institutional Ethics Committee, Dr. B. R. Ambedkar Medical College, Kadugondana Halli, Bangalore, India and consent was obtained from the participants and was informed of their right to withdraw anytime during the course of the study. Study Protocol Patients were involved based on the inclusion and exclusion criteria, non-probability purposive sampling technique. A total of 162 gestational diabetic patients were selected in the age group of 25-35 years based on the WHO criteria of diagnosis of gestational diabetes. Patients were matched with regard to blood sugar levels at Sakaria Hospital, Bangalore, India. Data on obstetrical information were recorded.All the patients were instructed to continue routine treatment which included counseling on diet and regular monitoring of blood glucose level, insulin therapy based on the blood glucose level, and regular dose of iron, folic acid, and calcium tablets from 24th week to till delivery. They were instructed to follow-up the visits regularly in the antenatal outpatient department. They were divided into test group (who underwent yoga practice) and control group (who did not undergo any yoga practice). The test group consisting of 82 patients was on insulin therapy. The test group was taught yoga and pranayama for 3 continuous months (from 24 weeks of gestation onwards), 1 h every day by yoga expert in the morning between 7.00-8.00 am and 8.00-9.00 am in two batches as per the time/batch chosen by the patients. The control group involved 80 patients and was also on insulin treatment and did not undergo any yoga practice. Protocol of yogic practices and pranayama used in the present study: 1. Loosening exercises for 10 min, which included loosening neck, loosening fingers, loosening wrist, shoulder rotation, twisting, hand stretch breathing, hands in and out breathing, ankle stretching. 2. Asanas for 20 min, which included a) standing - tadasana and ardhakatichakrasana, b) sitting - vajrasana, titali asana (purna and ardha), siddha yoni asana, c) supine - savasana (left lateral position). 3. Deep relaxation technique for 5-7 min. 4. Pranayama for 15 min which included nadi shuddi, sitali, sitakari, sadanta, bhramari pranayamas. Drop Outs During the study, out of 82 patients from yoga group, 7 of them dropped out and out of 80 patients from control group, 4 of them withdrew from the study due to personal reasons. Blood samples for fasting blood sugar (FBS), postprandial blood sugar (PPBS), glycosylated hemoglobin (HbA1c), and insulin requirement per day were estimated before the starting and at the end of 3-month period. HbA1c was estimated by Bio-Rad D-10TM . Inclusion criteria included those with a history of GDM between 24 and 28 weeks of gestation. Exclusion criteria involved those with polyhydramnios, multiple pregnancy, pregnancy induced hypertension (PIH), complicated pregnancy, cardiac problems, obesity. Sample size was determined by considering the results of previously published studies and taking standard normal variate of 0.84 for power of 80% and standard normal variate of 1.96 at 5% type 1 error.
  • 3. Balaji and Varne Effects of yoga and pranayama in gestational diabetes National Journal of Physiology, Pharmacy and Pharmacology 726 2017 | Vol 7 | Issue 7 Statistics The data obtained were analyzed using MedCalc Statistical Software version 12.7.8 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2014) and appropriate statistical methods such as mean, SD and t-test for paired data and categorical data were analyzed using Chi-square test (r × c table). P value was considered statistically significant below 0.05. RESULTS Tables 1-3 depicted very clearly that there is a significant decrease in blood glucose level in yoga group compared to control group and also the maternal and fetal outcome parameters have significantly improved among yoga group compared to control group. DISCUSSION In the present prospective study, 75 patients in yoga group and 76 in control group showed statistically significant difference between metabolic parameters and maternal and fetal outcome of mothers with GDM between yoga group and control group at P 0.01. Among yoga group, the FBS improved from 132.44 to 100.06 with P 0.001 compared to control group which showed the improvement from 133.45 to 111.23 with P 0.01. Similarly, the PPBS among yoga group showed improvement from 150.33 to 121.56 with P 0.001. Concordantly in a study conducted in Tamil Nadu, India, among yoga group, 24th week fasting blood glucose mean score was 122.99 mg/dl; after intensive practice of yoga, the mean score at 28th week was 106.31 mg/dl, 32nd week was 102.37 mg/dl, and 36th week was 90.27 mg/dl and the post prandial blood glucose mean score at 24th week was 160.45 mg/dl and after yoga, the mean score at 28th week was 140.14 mg/dl, 32nd week was 127.01 mg/dl, and 36th week was 117.13 mg/dl and concluded that there was a significant reduction in the fasting and postprandial blood glucose level in yoga group than control group at P 0.001 level of significance.[12] A randomized controlled study conducted by Sununta found that the intervention group showed significantly reduced fasting plasma glucose, 2-h postprandial blood glucose, and HbA1c in the intervention group with (P 0.05).[13] In another study which evaluated ten randomized controlled trials indicated that yoga intervention presented with lower incidences of prenatal disorders (P 0.05), and small gestational age (P 0.05), lower levels of pain and stress (P 0.05), and higher score of relationship (P 0.05) and suggested that yoga is a safe and more effective intervention during pregnancy.[14] Narendran et al. illustrated the effects of yoga in pregnant women, who were matched to controls. Pregnant women practiced yoga daily for 1 h, for 20-22 weeks, while the control group walked twice daily for 30 min. The study showed that in the group that practiced yoga, the incidence of preterm labor was statistically lower (P 0.0006) and birth weight was higher (P 0.01).[15] Rakhshani et al. showed that pregnant women who completed an 1 h yoga classes, 3 times a week, from 12 to 28 weeks of gestation, showed reduced rates of PIH, preeclampsia, gestational diabetes, and intrauterine growth restriction (P = 0.018, 0.042, 0.049, 0.05 respectively).[16] Field examined the benefits of yoga and pregnant women who were clinically depressed reporting that the yoga intervention group had longer gestational age and increased birth weight as compared to the control group receiving no yoga therapy.[17] Table 1: Metabolic parameters in patients of test group and control group Parameters Test group (n=75) Control group (n=76) At 24 weeks After 36 weeks At 24 weeks After 36 weeks FBS (mg/dl) 132.44 100.06** 133.45 111.23* PPBS (mg/dl) 150.33 121.56** 152.11 128.99* HbA1C 6.1±0.2 6.32±0.3 6.0±0.2 6.61±0.2 Requirement of insulin/day 26.22±7.5 18.34±4.3** 28.44±4.8 20.14±6.4* *P0.01, **P0.001. FBS: Fasting blood sugar, PPBS: Postprandial blood sugar Table 2: Comparison of maternal outcome of patients with GDM between test and control group Parameters Maternal outcome Test group n=75 (%) Control group n=76 (%) Weeks of gestation (at delivery) 37 13 (17.33) 42 (55.26) 37‑39 35 (46.66) 14 (18.42) 39‑42 25 (33.33) 19 (25) above 42 2 (2.66) 1 (1.31) Mode of delivery Normal 23 (30.66) 2 (2.63) Normal with episiotomy 28 (37.33) 3 (3.9) Forceps 12 (16) 15 (19.73) LSCS 12 (16) 56 (73.6) Complications during labor Perianal injuries 4 (5.33) 23 (30.26) Primary postpartum hemorrhage 2 (2.66) 4 (5.26) Prolonged labor 9 (12) 26 (34.21) No complications 60 (60) 23 (30.26) Chi‑square: (1) 25.38, df=3, P0.00. (2) 66.6, df=3, P0.00. (3) 38.79, df=3, P0.00. GDM: Gestational diabetes mellitus, LSCS: Lower segment caesarean section
  • 4. Balaji and Varne Effects of yoga and pranayama in gestational diabetes 727 National Journal of Physiology, Pharmacy and Pharmacology 2017 | Vol 7 | Issue 7 Another study by Martins and Pinto e Silva showed that women with pregnancy-related lumbar and pelvic pain had reduced pain after a 10 weeks yoga intervention (P 0.0058). The pain level was measured by a visual analog scale and by pain provocation tests.[18] In the present study, among yoga group, the insulin requirement per day reduced from 26.22 ± 7.5 to 18.34 ± 4.3 with P 0.001 compared to that among control group, the reduction was from 28.44 ± 4.8 to 20.14 ± 6.4 with P 0.01. We could not find studies to compare which addressed this aspect of insulin requirement per day. Limitations of the Present Study (i) Larger sample study involving patients of different geographical areas, ethnic background, religion, and customs will be more informative, (ii) fetal outcomes such as APGAR scoring, fetal anthropometry measurements were not considered, (iii) trend of maternal anthropometry during the study could not be analyzed, and (iv) studies including gestational diabetic patients on metformin and patients on insulin, both undergoing yoga and pranayama will be more informative for planning proper management of gestational diabetes. CONCLUSION Yoga and pranayama significantly decreases blood glucose level which in turn can prevent adverse maternal and fetal outcomes of GDM. Safety during pregnancy is paramount and exercises such as low exerting forces such as yoga can be safe for both mother and fetus.[19] ACKNOWLEDGMENT We are very thankful to all the mothers who took part in the present study. REFERENCES 1. Seshiah V, Balaji V, Balaji MS. Scope for prevention of diabetes--’focus intrauterine milieu interieur’. J Assoc Physicians India. 2008;56:109-13. 2. Seshiah V, Balaji V, Balaji MS, Paneerselvam A, Kapur A. Pregnancy and diabetes scenario around the world: India. Int J Gynaecol Obstet. 2009;104 Suppl 1:S35-8. 3. Anjalakshi C, Balaji V, Balaji MS, Ashalata S, Suganthi S, Arthi T, et al. A single test procedure to diagnose gestational diabetes mellitus. Acta Diabetol. 2009;46:51-4. 4. Coustan DR, Imarah J. Prophylactic insulin treatment of gestational diabetes reduces the incidence of macrosomia, operative delivery, and birth trauma. Am J Obstet Gynecol. 1984;150:836-42. 5. Hod M, Merlob P, Friedman S, Schoenfeld A, Ovadia J. Gestational diabetes mellitus. A survey of perinatal complications in the 1980s. Diabetes. 1991;40 Suppl 2:74-8. 6. Coustan DR. Pharmacological management of gestational diabetes: An overview. Diabetes Care. 2007;30 Suppl 2:S206-8. 7. Coustan DR, Nelson C, Carpenter MW, Carr SR, Rotondo L, Widness JA. Maternal age and screening for gestational diabetes: A population-based study. Obstet Gynecol. 1989;73:557-61. 8. Padayachee C, Coombes JS. Exercise guidelines for gestational diabetes mellitus. World J Diabetes. 2015;6:1033-44. 9. Taimini IK. The Science of Yoga. Madras, India: The Theosophical Publishing House; 1965. 10. Narendran S, Nagarathna R, Nagendra HR.Yoga for Pregnancy. London: Cassell Illustrated; 2008. 11. Balaji PA, Varne SR, Ali SS. Effects of yoga - Pranayama practices on metabolic parameters and anthropometry in type 2 diabetes. Int Multidiscip Res J. 2011;1(10):1-4. 12. Abirami P, Raj J. Impact of yoga on blood glucose level among mother with gestational diabetes mellitus at government hospital, Tambaram, Chennai, Tamil Nadu. Indian J Health Wellbeing. 2013;1(4):99-105. 13. Youngwanichsetha S, Phumdoung S, Ingkathawornwong T. The effects of mindfulness eating and yoga exercise on blood sugar levels of pregnant women with gestational diabetes mellitus. Appl Nurs Res. 2014;27(4):227-30. 14. Jiang Q, Wu Z, Zhou L, Dunlop J, Chen P. Effects of yoga intervention during pregnancy: A review for current status. Am J Perinatol. 2015;32(6):503-14. 15. Narendran S, Nagarathna R, Narendran V, Gunasheela S, Nagendra HR. Efficacy of yoga on pregnancy outcome. J Altern Complement Med. 2005;11(2):237-44. 16. Rakhshani A, Nagarathna R, Mhaskar R, Mhaskar A, Thomas A, Gunasheela S. The effects of yoga in prevention Table 3: Comparison of fetal outcome and birth weight of baby of patients with GDM between test and control group Parameters Fetal outcome Test group (n=75) Control group (n=76) Fetal outcome Congenital malformation 2 (2.66) 4 (5.26) Fetal macrosomia 22 (29.33) 40 (52.6) Intra uterine growth restriction 2 (2.66) 13 (17.10) Intrauterine fetal death 1 (1.33) 2 (2.63) No complications 48 (64) 17 (22.36) Birth weight of baby (kg) 2.5 5 (6.6) 16 (21.05) 2.5‑3.5 48 (64) 25 (32.89) 3.5 22 (29.33) 35 (46.05) Chi‑square: (1) 29.07, df=4, P0.00. (2) 15.96, df=2, P0.01. GDM: Gestational diabetes mellitus
  • 5. Balaji and Varne Effects of yoga and pranayama in gestational diabetes National Journal of Physiology, Pharmacy and Pharmacology 728 2017 | Vol 7 | Issue 7 of pregnancy complications in high-risk pregnancies: A randomized controlled trial. Prev Med. 2012;55(4):333-40. 17. Field T, Diego M, Hernandez-Reif M, Medina L, Delgado J, Hernandez A. Yoga and massage therapy reduce prenatal depression and prematurity. J Bodyw Mov Ther. 2012;16(2):204-9. 18. Martins RF, Pinto e Silva JL. Treatment of pregnancy- related lumbar and pelvic girdle pain by the yoga method: A randomized controlled study. J Altern Complement Med. 2014;20(1):24-31. 19. Artal R, O’Toole M. Guidelines of the American College How to cite this article: Balaji PA, Varne SR. Physiological effects of yogasanas and pranayama on metabolic parameters, maternal and fetal out come in gestational diabetes. Natl J Physiol Pharm Pharmacol 2017;7(7):724-728. Source of Support: Nil, Conflict of Interest: None declared. of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med. 2003;37(1):6-12.