Maria Lúcia Rocha Oppermann

Recomendações da 2ª. Reunião do Grupo de Trabalho em Diabetes e Gravidez

Clinical guidelines for the management of gestational and pre-gestational diabetes were prepared by the Diabetes and Pregnancy Task Force, during the XI Brazilian Diabetes Congress, held in 1997. A new meeting was held in 2001 to revise recommendations for screening, diagnosis and management of gestational diabetes, based on the new evidences generated on these issues. Universal screening of pregnant women is advised beginning at the 20th week of gestation, using fasting plasma glucose. Cut points of 85mg/dl or 90mg/dl are used to classify a positive screening. A 75g oral glucose tolerance test is performed if the screening test is positive. The diagnostic cut points suggested to define glucose alterations are a fasting plasma glucose ³110mg/dl or a 2h plasma glucose ³140mg/dl. Endocrine and obstetric management of gestational diabetes as well as a review on pre-gestational diabetes management are also presented.

Serum Vitamin D Insufficiency Is Related to Blood Pressure in Diabetic Pregnancy

BACKGROUND Vitamin D deficiency in pregnancy has been associated with an increased risk of preeclampsia. However, the association between serum vitamin D and blood pressure in pregnant women has been scarcely evaluated, particularly in women with a high risk of developing hypertensive disorders of pregnancy. We sought to evaluate the association between serum 25-hydroxyvitamin D and blood pressure in pregnant women with gestational diabetes mellitus (GDM). METHODS A cohort of 184 pregnant women with GDM was followed during the third trimester of pregnancy and early puerperium. Blood pressure was recorded in all prenatal visits, and serum vitamin D was measured by chemiluminescence immunoassay. Pearsons coefficients and multiple linear regressions were used to study predictors of blood pressure levels. RESULTS Women with vitamin D insufficiency (<30ng/mL; n = 159) had higher systolic and diastolic blood pressure than the remaining participants. In white women (n = 136), serum vitamin D levels presented a significant negative correlation with systolic blood pressure at the beginning (r = -0.268; P = 0.002) and at the end of the third trimester (r = -0.203; P = 0.02), and vitamin D significantly affected systolic blood pressure after adjusting for confounders. This was not observed in women of other ethnicities. CONCLUSIONS In this cohort of pregnant women with GDM, vitamin D insufficiency was associated with higher blood pressure, and in white women, serum vitamin D was an independent predictor of systolic blood pressure during pregnancy.

Office hysteroscopy study in consecutive miscarriage patients.

OBJECTIVE To assess the prevalence of uterine anatomical abnormalities found by office diagnostic hysteroscopy in a population of patients experiencing more than two consecutive miscarriages and compare the prevalence of uterine abnormalities between patients with two miscarriages and those with three or more consecutive miscarriages. METHODS A cross-sectional study of 66 patients with two or more consecutive miscarriages diagnosis was conducted. Patients were divided into two groups: Group A (up to two miscarriages, 23 patients), and Group B (3 miscarriages, 43 patients). They underwent an outpatient diagnostic hysteroscopy study, with either congenital or acquired abnormalities of the uterine cavity being identified. RESULTS Uterine changes were found in 22 (33.3%) patients, with 9 cases of congenital changes [arcuate uterus (4 cases), septate uterus (2 cases), and bicornuate uterus (1 case)], and 13 patients with acquired changes [intrauterine adhesions (7 cases), endometrial polyp (4 cases), and uterine leiomyoma (2 cases)]. No significant differences were found between the groups as regarding both acquired and congenital uterine changes. A positive correlation was found between anatomical changes on hysteroscopy and number of miscarriages (r = 0.31; p = 0.02). CONCLUSION Patients with more than two miscarriages have a high prevalence of uterine cavity abnormalities diagnosed by hysteroscopy; however there are no differences in prevalence or distribution of these lesions related to the number of recurrent miscarriages.

Diabetes gestacional: um algoritmo de tratamento multidisciplinar

Effective treatment of gestational diabetes is important as an attempt to avoid unfavorable maternal and fetal outcomes. The objective of this paper is to describe the available therapies to optimize gestational diabetes treatment and to suggest a multidisciplinary approach algorithm. Nutrition therapy is the first option for the majority of these pregnancies; light to moderate physical activity is recommended in the absence of obstetrical contraindications. Medical treatment is recommended if glycemic control is not achieved or if excessive fetal growth is detected by ultrasound. Insulin is the standard treatment although oral antidiabetic drugs have recently been considered an effective and safe option. The monitoring of gestational diabetes treatment includes capillary glucose measurements and evaluation of fetal abdominal circumference by ultrasound performed around the 28th gestational week.

Vitamin D Deficiency Increases the Risk of Adverse Neonatal Outcomes in Gestational Diabetes

Background Gestational diabetes mellitus (GDM) and vitamin D deficiency have been associated with increased risk of adverse perinatal outcomes but the consequences of both conditions simultaneously present in pregnancy have not yet been evaluated. Our objective was to study the influence of vitamin D deficiency in neonatal outcomes of pregnancies with GDM. Methods 184 pregnant women with GDM referred to specialized prenatal monitoring were included in this cohort and had blood sampled for 25-hydroxyvitamin D measurement. Vitamin D was measured by chemiluminescence and deficiency was defined as < 20 ng/mL. Participants were followed until puerperium and adverse neonatal outcomes were evaluated. Results Newborns of women with vitamin D deficiency had higher incidences of hospitalization in intensive care units (ICU) (32 vs 19%, P = 0.048), of hypoglycemia (any, 17.3 vs 7.1%, P = 0.039requiring ICU, 15.3 vs 3.6%, P = 0.008), and were more frequently small for gestational age (SGA) (17.3 vs 5.9%, P = 0.017). After adjustment, relative risk (RR) for hypoglycemia requiring ICU was 3.63 (95%CI 1.09–12.11) and for SGA was 4.32 (95%CI 1.75–10.66). The incidence of prematurity, jaundice and shoulder dystocia was no statistically different between groups. Conclusions In this cohort of pregnant women with GDM, vitamin D deficiency was associated with a major increase in the incidence of adverse neonatal outcomes such as SGA newborns and neonatal hypoglycemia.

Postpartum glucose tolerance status 6 to 12 weeks after gestational diabetes mellitus: a Brazilian cohort

OBJECTIVES The aims of this study were to estimate the local rate of postpartum diabetes screening after gestational diabetes mellitus (GDM) pregnancies, and to identify clinical variables associated with retesting rates and with the persistence of decreased glucose tolerance. SUBJECTS AND METHODS Prospective cohort of GDM women with prenatal delivery at a specialized center, from November 2009 to May 2012. All women were advised to schedule a 6 weeks postpartum 75-g oral glucose tolerance test (OGTT). RESULTS Of the 209 women included, 108 (51.7%) returned to be tested with fasting plasma glucose (n=14), OGTT (n=93) or random glucose (n=1). Return was associated with lower parity rate (2 vs. 3, p<0.001) and higher pregnancy 2-h OGTT (165 vs. 155 mg/dL, p=0.034), but not with socio-demographic characteristics. Four women (3.7%) had diabetes, 22 (20.4%) had impaired fasting glucose or impaired glucose tolerance. Persistent hyperglycemia was associated with a positive family history of diabetes (relative risk-RR 2.41, p=0.050), diagnostic 2-h OGTT in pregnancy (RR 1.01, p=0.045), insulin use during pregnancy (RR 2.37, p=0.014), and cesarean section (RR 2.61, p=0.015). CONCLUSIONS Even though postpartum abnormalities were frequent in GDM, rates of postpartum diabetes screening were undesirably low. As no specific clinical profile defines who will adhere to postpartum testing, it is essential to encourage all women to reevaluate their glucose status, particularly those with a family history of diabetes and more severe hyperglycemia.

Weight gain adequacy and pregnancy outcomes in gestational diabetes: a meta-analysis

The Institute of Medicine updated guidelines for gestational weight gain in 2009, with no special recommendations for gestational diabetes. Our objectives were to describe the prevalence of weight gain adequacy and their association with adverse pregnancy outcomes in gestational diabetes. We searched MEDLINE, EMBASE, COCHRANE and SCOPUS. We calculated the pooled prevalence of gain adequacy and relative risks for pregnancy outcomes within Institute of Medicine categories. Thirty‐three studies/abstracts (88,599 women) were included. Thirty‐one studies provided data on the prevalence of weight gain adequacy; it was adequate in 34% (95% CI: 29–39%) of women, insufficient in 30% (95% CI: 27–34%) and excessive in 37% (95% CI: 33–41%). Excessive gain was associated with increased risks of pharmacological treatment, hypertensive disorders of pregnancy, caesarean section, large for gestational age and macrosomic babies, compared to adequate or non‐excessive gain. Weight gain below the guidance had a protective effect on large babies (RR: 0.71; 95% CI: 0.56–0.90) and macrosomia (RR 0.57; 95% CI 0.40–0.83), and did not increase the risk of small babies (RR 1.40; 95% CI 0.86–2.27). Less than recommended weight gain would be beneficial, while effective prevention of excessive gain is of utmost importance, in gestational diabetes pregnancies. Nevertheless, no ideal range for weight gain could be established.

Risk factors for gestational diabetes mellitus in a sample of pregnant women diagnosed with the disease

Background The known risk factors for Gestational Diabetes Mellitus (GDM) are advanced age (≥35 yrs.), overweight or obesity, excessive gestational weight gain, excessive central body fat deposition, family history of diabetes, short stature (<1.50 m), excessive fetal growth, polyhydramnios, hypertension or preeclampsia in the current pregnancy, history of recurrent miscarriage, offspring malformation, fetal or neonatal death, macrosomia, GDM during prior pregnancies and polycystic ovary

Clinical characteristics of women with gestational diabetes - comparison of two cohorts enrolled 20 years apart in southern Brazil

CONTEXT AND OBJECTIVE: The prevalence and characteristics of gestational diabetes mellitus (GDM) have changed over time, reflecting the nutritional transition and changes in diagnostic criteria. We aimed to evaluate characteristics of women with GDM over a 20-year interval. DESIGN AND SETTING: Comparison of two pregnancy cohorts enrolled in different periods, in university hospitals in Porto Alegre, Brazil: 1991 to 1993 (n = 216); and 2009 to 2013 (n = 375). METHODS: We applied two diagnostic criteria to the cohorts: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/World Health Organization (WHO); and National Institute for Health and Care Excellence (NICE). We compared maternal-fetal characteristics and outcomes between the cohorts and within each cohort. RESULTS: The women in the 2010s cohort were older (31 ± 7 versus 30 ± 6 years), more frequently obese (29.4% versus 15.2%), with more hypertensive disorders (14.1% versus 5.6%) and at increased risk of cesarean section (adjusted relative risk 1.8; 95% confidence interval: 1.4 - 2.3), compared with those in the 1990s cohort. Neonatal outcomes such as birth weight category and hypoglycemia were similar. In the 1990s cohort, women only fulfilling IADPSG/WHO or only fulfilling NICE criteria had similar characteristics and outcomes; in the 2010s cohort, women only diagnosed through IADPSG/WHO were more frequently obese than those diagnosed only through NICE (33 ± 8 kg/m2 versus 28 ± 6 kg/m2; P < 0.001). CONCLUSION: The epidemic of obesity seems to have modified the profile of women with GDM. Despite similar neonatal outcomes, there were differences in the intensity of treatment over time. The IADPSG/WHO criteria seemed to identify a profile more associated with obesity.

Response to a letter to the editor addressing the publication "Effect of nonsurgical periodontal therapy and strict plaque control on preterm/low birth weight: a randomized controlled clinical trial".

1. The traditional classification based on a distinction between “spontaneous” and “medically indicated” preterm birth proposed by Dr. Lopez has long been debated in obstetrics due to its inherent ambiguity and it is no longer in use. To properly address this issue, the Global Alliance to Prevent Prematurity and Stillbirth task force established a new classification system for the preterm birth syndrome intended for clinical and research use [1]. The 2009 classification was based on the following five components: (1) maternal conditions prior to presentation for birth, (2) fetal conditions prior to presentation for birth, (3) placental pathologies, (4) signs of early labor, and (5) route (pathway) of birth (started spontaneously or by the doctor). Notably, risk factors or the route of delivery (vaginal or cesarean) are explicitly omitted in this new classification [2]. Whereas our original publication did not report results according to the above-mentioned classification, data collected during the study were retrieved and the results are presented below for the reader’s sake. As reported previously, 14 and 17 preterm births occurred in the control and test groups, respectively. Four out of the 14 preterm births in the control group had significant maternal conditions as defined by the new classification, namely one case of chronic hypertension, one case of preeclampsia, and two cases of urinary tract infection. The remaining ten women had no maternal, fetal, or placental factors for preterm birth that could be identified. In the test group, 6 out of the 17 preterm births showed significant pathological conditions: one case of preeclampsia, one case of depressed mood, two cases of gestational diabetes, and two cases of urinary tract infection. Eleven cases of preterm birth in the test group did not have any maternal, fetal, or placental factors that could be identified. No cases of fetal or placental pathological conditions were identified in any of the participants. Spontaneous delivery occurred in 10 out of 14 women in the control group and in 11 out of 17 women in the intervention group (71.4 vs. 64.7 %, p=0.70). Thus, no significant differences could be observed between groups when the most current classification system is used, corroborating our initial findings and conclusions. P. Weidlich (*) : T. Fiorini :M. L. Musskopf : J. M. da Rocha : M. L. R. Oppermann : C. K. Rösing : R. V. Oppermann Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil e-mail: patricia.weidlich@ufrgs.br