diabetes.pdf
TRANSCRIPT
-
Diabetes Gestacional
Standards of Medical Care in Diabetes 2013
Williams OBSTETRICS 24 Ed
American Diabetes Association ADA
Nature Reviews | Endocrinology volume 8 | november 2012 | 639
Current Management of Gestational Diabetes Mellitus
Guido Menato et all.- Expert Rev of Obstet Gynecol. 2008;3(1):73-91
Uptodate 2015
UPC 23/02/2015 Marco Antonio Martina Chvez
1
-
Diabetes Mellitus (siglo I gr correr a travs Areteo de
Capadocia y en 1675 Thomas Wllis: miel orina)
Es una enfermedad metablica endocrinolgica crnica
caracterizada por el dficit relativo o absoluto de insulina
(Alteraciones en la secrecin, o accin de la insulina) resultando
en hiperglicemia perdida de la homeostasis de la glucosa
Causas: (Multifactorial, gentica, inmunolgica, adquirida)
Deficiencia de insulina
Resistencia a la insulina
Impacto de la Hiperglicemia:
Riesgos para la madre y su feto
Disfuncin multi orgnica
Mortalidad elevada
Manifestaciones:
Intolerancia a la glucosa
Cetoacidosis
Complicaciones crnicas
2
-
3
-
4
-
5
-
Epidemiologia
Diabetes en la Gestacin
4 - 6% de los embarazos en USA se complican con DM,
representan 50 - 150,000 / ao. 30 35% recurrencia
88% GDM, el 8% DM tipo II, el 4% DM tipo 1
Epidemia actual: Obesidad y diabetes: ms casos de diabetes tipo
2 en las MEF y ms casos de mujeres embarazadas con diabetes
tipo 2 no diagnosticada
Complicacin mdica ms comn de la gestacin
DM Gestacional 90%
DM Preexistente 10%
6
-
El estudio epidemiolgico multinacional HAPO
(Hyperglucemia and Pregnancy Outcome Adverse, 25.000
mujeres embarazadas), demostr que el riesgo de los
resultados maternos, fetales y neonatales adversos aument
continuamente en funcin de la glucemia materna desde las
24 - 28 semanas
Este nuevo enfoque aument la prevalencia de DMG ya que
basta un solo valor anormal para hacer su diagnstico (de 4
al 6%)
GDM es ms comn entre las personas de ascendencia
asitica o etnia hispana y menos comn en personas de
ascendencia europea; e incidencia intermedia en las
mujeres afroamericanas
7
-
HAPO
A > hiperglicemia, sea en ayunas, a 1
2 hrs > LGA
8
-
Diabetes Gestacional: Definicin
Cualquier grado de Intolerancia a la glucosa que se inicia o
diagnostica por primera vez durante el embarazo, ya sea que la
hiperglicemia persista o no despus de l.
No es endocrinolgica. Es contrainsulnica o de resistencia a
la insulina (Insulinasa placentaria, > cortisol)
Incluye embarazadas con DM 1 2 no Dx previamente
El 90 % de embarazadas diabticas constituyen ARO:
macrosoma, sufrimiento fetal y complicaciones metablicas
neonatales (HAPO)
Por lo tanto, GDM slo representa los niveles elevados de
glucosa en un momento determinado: embarazo
Se trata de un pncreas insuficiente. Embarazo normal:
compensa con insulina (si pncreas N)
9
-
Metabolismo de los Carbohidratos
Efectos del embarazo normal:
En el 1er trimestre hay un en la sensibilidad insulnica.
Compensa con > secrecin de insulina si el pncreas est
normal (30%)
Hay un del volumen plasmtico en la gestacin temprana y
un de la utilizacin de glucosa fetal a medida que avanza el
embarazo
progresivo de la resistencia tisular a la insulina
Supresin de la respuesta del glucagn
de Prolactina, cortisol
HPL tiene efectos semejantes a la Hormona del Crecimiento
(comparten 87% de sus amino cidos)
10
-
Hipoglucemia en
ayunas leve
Hiperglucemia
postprandial
Hiperinsulinemia
Debido a la resistencia
perifrica a la insulina
lo que asegura un
suministro adecuado de
glucosa para el beb
11
-
Metabolismo de la glucosa en el embarazo
Precozmente en el Embarazo : Estrgenos y Progesterona inducen hiperplasia de clulas Beta del Pncreas con
aumento de Insulina, disminucin perifrica de glucosa y
disminucin de los niveles de glicemia en ayunas en un 10 a
20 %
En el 2 y 3er. Trimestre la demanda de nutrientes fetal y moviliza depsitos de glucosa materna, glucogenolisis
heptica y hay resistencia Insulnica mediada por
Lactgeno Placentario (correlacionado con la masa
placentaria), Prolactina, Cortisol
Estado anablico
de las reservas de grasa materna
de la concentracin de FFA
de las necesidades de insulina
12
-
Efectos Diabetgenos del Embarazo
Resistencia a la Insulina (perifrica y > en los msculos):
Debido a las hormonas placentarias HCG, HLP (Producida por el
sincitiotrofoblasto de la placenta, promueve la liplisis
cidos grasos libres y la absorcin de glucosa materna y la
gluconeognesis: es "Anti-insulina), Cortisol, Estrgenos,
Progesterona (que interfieren con la relacin entre insulina y
glucosa), Destruccin de la Insulina por el Rin y la Placenta
(3 veces > que en no gestantes). La respuesta normal es el de
Insulina basal y la post prandial 1.5 a 2.5 veces, si ello no
ocurre son intolerantes a la Glucosa
Aumento de Lipolisis: Madre usa grasas para caloras y guarda
Glucosa para el feto. : Ac. Grasos libres, Oxidacin glucosa,
Glicolisis en msculo
Cambios en la Glucognesis: Feto usa ms Alanina y otros
aminocidos, privando a la madre de sustrato para
Gluconeognesis
13
-
Fisiopatologa
La DMG es causada por una reduccin (en la primera fase) en
la funcin de las clulas del pancreas que lleva a una
disfuncin de ellas
Las alteraciones en la sensibilidad a la insulina llevan a
alteraciones del metabolismo de las grasas, carbohidratos,
aminocidos etc.
Ms evidente entre las 26 y 30 semanas
Insulinasa: Producto placentario que puede jugar un rol <
Potencia Diabetgena y mxima secrecin: (1: dbil, 5: fuerte)
Estradiol 1 26 semanas
Prolactina 2 10 semanas
hPL 3 26 semanas
Cortisol 5 26 semanas
Progesterona 4 32 semanas
14
-
Crculo Vicioso?
15
-
Factores de Bajo Riesgo de DG
Edad de 25 aos
No hispanos, afro, nativo americano
IMC < 25 (peso normal antes del embarazo)
No intolerancia a la glucosa previa
No resultados adversos obsttricos anteriores
No tener historia de diabetes familiar de primer grado
16
-
Factores de Alto Riesgo de DG
Historia familiar de Diabetes Mellitus
Edad > 30 aos
Obesidad marcada IMC > 30
Diabetes Gestacional previa
Antecedentes:
Obito de causa inexplicable
Malformaciones Fetales
Macrosoma previa
Dao Fetal previo no explicado
Feto actual crece sobre el percentil 90
Polihidramnios previo o actual
Glucosuria primera orina matinal
Parto prematuro
ITU recidivante
HTA
Moniliasis
Negros, Hispanos 17
-
Screening para Alto Riesgo
Tan pronto como sea posible. Repita en 24 a 28 semanas si
los valores son negativos o antes si aparecen sntomas de
glucosuria desarrollar
75 g de glucosa
15% de los pacientes positivos
Valor > 10.3: diagnstico de DMG (no necesita TTG)
24 - 28 semanas de rutina
No se necesita que sea en ayunas
Testear en la 1ra CPN si hay historia de DMG previa
Testear a las 12 - 24 semanas si hay factores de riesgo
18
-
19
-
20
-
21
-
Cambios Patolgicos en la DG
Resistencia a la
Insulina
Deficiencia de
Insulina
22
-
Hiperglicemia materna Hiperglicemia fetal Hiperinsulinemia fetal (promueve el almacenamiento de exceso
de nutrientes Crecimiento fetal anormal: Macrosoma (> 4000 o P90). Deterioro del Bienestar Fetal. el catabolismo del exceso de nutrientes e el uso de la energa
Anomalas congnitas (3v >, 50% mueren). 4 a 8 v > riesgo en
DM Pre existente. 600 v en Sndrome de Regresin Caudal. Defectos ms comunes: SNC, CV, Renal, GI
Trauma del nacimiento: distocia de hombro y las
complicaciones relacionadas
RCIU: Hipoxia crnica (Madres DM Tipo I). Por afeccin vascular
materna, hiperG materna hiperglicemia fetal del lactato y pO
2 sangre fetal. Tambin: glicosilacin Hb Hb A1c
liberacin O2 placenta
Abortos (3 v >, relacionados con control de la glicemia) HbA1c >
12. Hasta 40%
DG: Riesgos Fetales
23
-
24
-
Policitemia e Hiperviscocidad (HiperG > eritropoyetina fetal que
puede llevar a la isquemia tisular e infarto)
Hipoglicemia Neonatal: Debida a hiperG materna
hiperinsulinemia. Nace: ya no hay hiperG materna y sigue alta la
hiperinsulinemia fetal Hipoglicemia fetal: convulsiones, coma,
dao cerebral
Hipocalcemia Neonatal
Hiperbilirrubinemia: 25%. Es por la policitemia
Cardiomiomatia Hipertrfica y Congestiva
Sindrome de Distres Respiratorio: 5 6 v > frec. Pulmn inmaduro
Tolerancia alterada a la glucosa en la infancia
Aumento de la acidosis
Hipomagnemesia
Alteraciones del desarrllo cognitivo
Natimuertos: sin Tto, > 36 semanas
DG: Riesgos Neonatales
25
-
de almacenamiento de
oxgeno fetal e hipoxia fetal
episdica
Hipoxia fetal episdica
conduce a de catecolaminas
que provocan:
Hipertensin fetal
Remodelacin cardaca y la
hipertrofia
El de la eritropoyetina,
glbulos rojos, hematocrito
La mala circulacin fetal e
hiperbilirrubinemia
26
-
Mortalidad materna 0.5 % es 5 a 10 veces mayor
Traumas o injurias del parto
Parto quirrgico: Cesrea
50% de riesgo de desarrollar de DM Tipo II
Riesgo de recurrencia de la DMG: 30 - 50%
Polihidramnios: 10%. > 2000 cc. > riesgo DPP, parto
prematuro
Neuropata, Retinopata Diabtica
Preeclampsia: 2 veces >. 40% HTS Crnica
ITU (orina rica en glucosa y estasis urinaria)
Cetoacidosis
DG: Riesgos Maternos
27
-
28
-
29
-
30
-
31
-
32
-
33
-
Clasificacin
1. Diabetes Tipo I (Destruccin clulas B, velocidad de
destruccin variable). AC. Destruyen 80 90%. Insulina
insuficiente para la regulacin de la glucosa. Umbral renal 180
mg/dl. Aumento del Catabolismo (protelisis). Formacin de
cuerpos cetnicos y > glucosa. Acidosis (disminucin de
niveles de HCO3 renal). Cetoacidosis (descompensacin en
DB). Hiperglicemia, Deshidratacin. Desequilibrio electroltico.
Acidosis Metablica
Mediada inmunolgicamente
Ideoptica: cetosis, asociacin Familiar
2. Diabetes Tipo II: Factor de Resistencia a Insulina. Etiologa no
bien definida. No factores inmunolgicos. Asociacin familiar.
Niveles de insulina normales o elevados
3. Diabetes Gestacional: Se inicia durante la gestacin.
Asintomtica. Predispone a DBM tipo 2
34
-
35
-
Clase Inicio
Glucosa
Plasmtica
en ayunas
Glucosa 2 hr Post
Prandial
Terapia
A1
A2
Gestacional
Gestacional
< 105 mg/dl
> 105 mg/dl
< 120 mg/dl
20
10 a 19
< 10
Cualquiera
Cualquiera
Cualquiera
< 10
10 a 19
> 20
Cualquiera
Cualquiera
Cualquiera
No
No
Retinopata Benigna
Nefropata
Retinopata Proliferativa
Corazn
insulina
insulina
insulina
insulina
insulina
insulina
36
-
Recomendaciones
Hacer screening en la primera visita prenatal en pacientes con factores
de riesgo usando los criterios de Dx estndar para D/C DM Tipo 2 (B)
En las mujeres embarazadas que no saben que tienen diabetes, hacer
screening a las 24 - 28 semanas, con 75 g de glucosa TTOG 2 h y hacer el
diagnstico de acuerdo a los puntos de corte (B)
Screening a mujeres con GDM con diabetes persistente en 6 - 12 semanas
post parto, utilizando el TTOG y el Dx de acuerdo criterios de Dx de las
embarazadas (E)
Mujeres con antecedentes de DMG deben hacerse una revisin a lo largo
de toda su vida para Dx diabetes o prediabetes al menos c/3 aos (B)
Las mujeres con antecedentes de DMG que se les encuentra prediabetes
deben recibir Metformina ms intervenciones de cambio de estilo de vida
para prevenir la diabetes (A)
37
-
Puntos Clave
La DMG esta asociada con un modesto incremento en los resultados
adversos perinatales, un incremento de riesgo de obesidad en sus hijos y
un alto riesgo de desarrollar subsecuentemente Diabetes Mellitus en la
madre
La DMG es tratada con dieta, es decir nutricionalmente, insulina or
antidiabticos orales pueden ser agregados si los niveles de glucosa
maternos y/o parmetros de crecimiento fetal indican un suficiente alto
riesgo de complicaciones perinatales
Manejo a largo plazo de las madres incluye la evaluacin del nivel y tipo de
diabetes y de evaluacin de nuesvos estilos de vida y agentes
farmacolgicos para mujeres con tipo II de diabetes
Manejo a largo plazo de sus hijos debera enfocar la deteccin y mitigacin
del desarrollo de la obesidad y de sus complicaciones
38
-
39
-
Al menos hay tres causas subyacentes distintas de disfuncin de las clulas
En primer lugar, algunas mujeres tienen marcadores circulantes inmunolgicos
(anticuerpos anti - clulas de los islotes anticuerpos a la glutamato
descarboxilasa) que son diagnosticados en la evolucin de diabetes mellitus tipo
1. La frecuencia de estos auto - anticuerpos es generalmente < 10% de todas las
mujeres con GDM y tiende a ser paralela a la prevalencia en DMT1
En segundo lugar, algunas mujeres tienen variantes genticas que son diagnstico
de las formas monognicas de diabetes. Estas mujeres pueden tener subtipos de
diabetes de comienzo en la madurez de los jvenes y de acuerdo a su carga
gentica materna de DM. Datos sistemticos sobre la frecuencia de estas formas
monognicas de diabetes en GDM son limitados, pero parecen ser raros,
representando el 1-5% de los casos
En tercer lugar, la presencia de los defectos de clulas que subyacen en la GDM
propios de la obesidad y la resistencia crnica a la insulina. Este grupo representa
la mayora de los casos de diabetes gestacional, por lo que muchos clnicos ven a
la GDM como una forma de evolucin de la diabetes mellitus tipo 2
>ria de las mujeres que hacen DMG tienen una disfuncin crnica y no parecera
adquirido en el embarazo. La obesidad y la gestacin favoreceran su aparicin.
40
-
41
-
Se estima que aproximadamente 10%
de las mujeres con diabetes
gestacional tienen diabetes mellitus
poco despus del parto
El resto desarrolla diabetes mellitus a
tasas de 20 - 60% dentro de 5 a 10
aos
42
-
Primera visita perinatal o en hospitalizacin
Revise las pruebas de laboratorio de rutina prenatal
Exmenes de orina para proteinuria y depuracin de creatinina
en 24 horas
Examen basal de retina: Para diabticos tipo 1
EKG: Para diabticos tipo 1
Pruebas de funcin tiroidea: Para diabticos tipo 1
Hemoglobina A1C
Ecocardiograma fetal para diabticos pregestacional
43
-
Monitoreo de la Glucosa en la casa
En ayuno y 2 horas post-prandial
Valores antes de las comidas slo si se usa escala mvil de
insulina de accin corta
Valores tempranos en la maana si se sospecha hipoglucemia
Asegrese de que el medidor de glucosa este calibrado
-
Indicaciones para la Hospitalizacin
Nauseas y vomitos persistentes
Infeccin materna
Cetoacidosis diabtica
Mal control o no cumplimiento
Labor pretermino
45
-
Diagnstico
Dos glicemias ayuno > 105 mg/dl
TTGO 75gr > 140 mg/dl a las 2 horas
Cualquier glicemia mayor a 200 mg/dl
Triaje: Primer control Embarazo de glicemia en ayuno
TTGO 75 gr entre 24 - 28 semanas y repetir
entre 32 - 34 semanas
46
-
Manejo:
Objetivo: optimizar los niveles de glucosa sangunea
para minimizar los resultados adversos neonatales
Dieta: tiene lugar
Autocontrol Domiciliario
Ejercicios
Antidiabticos orales
Terapia Insulnica
Diabetes Gestational
47
-
Manejo: Dieta 30 - 35 Kcal. mnimo 1800 Kcal
IMC > 27: 25 kcal / kg / ideal de peso corporal / d
IMC 20 26: 30 kcal / kg / ideal de peso corporal / d
IMC < 20: 38 kcal / kg / ideal de peso corporal / d
55% Carbohidratos (180 200 g), 25% de Protenas (1.3
1.5 g /kg), 20 - 30% de grasas
Ganancia normal de peso 10 - 12 kg (igual que Normal)
Evitar la cetosis
Programa de ejercicio liberal para optimizar el control
de la glucosa sangunea
Diabetes Gestational
48
-
Si la hiperglicemia persiste despus de 1 semana de control
diettico: proceder a usar Insulina
06 - 14 semanas 0.5 u / kg / day
14 - 26 semanas 0.7 u / kg / day
26 - 36 semanas 0.9 u / kg / day
36 40 semanas 1 u / kg / day
Diabetes Gestational
49
-
Control Glicemia
Glicemia de ayunas: Menor de 105
Glicemia Post prandial: Menor de 120
Insulina: 0.3 - 0.5 u / kg
Insulina repartir 2/3 diurnos y 1/3 nocturnos
Insulina NPH: 0.1 - 0.3 u / kg
Insulina Cristalina 2 a 4 U. Pre almuerzo y comida
Lo ms frecuente: mezcla de NPH y Cristalina dos dosis diarias
90 % se controlan con Dieta
Restriccin calrica 33% en obesas
50
-
Dieta de la ADA Asociacin Americana de Diabetes
Evitar las comidas abundantes con alto porcentaje de hidratos de
carbono simples. No sacarosa. Consumir fibra 20 35 gr/d
Tres comidas pequeas con tres bocadillos son los preferidos
Los alimentos con bajo ndice glucmico liberan caloras en el
intestino lentamente y mejorar el control metablico
El contenido calrico:
35 caloras / kg de peso corporal ideal ( 15 calorias / IBW libra)
No menos de 1800 caloras y no ms de 2800
Paciente Pequeo 1800 caloras
Paciente Mediano 2200 caloras
Paciente Grande 2400 caloras
51
-
Contenido de almidn en los alimentos e Indice Glicmico
Bajo Cebada 33
Legumbres / Frejoles 30
Panes multigranos 40
Copos de avena 50
Intermedio Bebidas sin alcohol 60
Leche descremada 34
Yogurt 30 - 40
Helado (bajas grasas) 50
Alto Papas 85
Copos de maz 77
Arroz inflado 85
Pan Integral 70
Galletas 81
Arroz 83
Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load
values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
52
-
Control Obsttrico
Normal hasta las 28 semanas, luego cada 15 das hasta las
34 semanas y semanal hasta el parto
Altura uterina, EPF, Volumen LA, Control PA
Cetonuria (cetosis de ayuno)
Urocultivo primer trimestre y 28 semanas
Condicin Fetal desde 34 semanas
Insulinodependiente: Patologa mdica u obsttrica control
diario
Ecografa: medir Circunferencia abdominal > p95
53
-
Evaluacin del Bienestar Fetal en DG
Preconcepcion Control Glicmico Materno
8 - 10 semanas Medicin Ecogrfica de LCR
16 semanas AFP Materna serica
20 - 22
semanas
ECO de alta resolucin: ecocardiografa fetal en
mujeres con control subptimo de su diabetes en el
1er CPN
24 semanas Medidas del crecimiento fetal por ECO
28 semanas Autocontrol materno diario de los movimientos
fetales
32 semanas Medidas del crecimiento fetal por ECO
34 semanas Test Biofsicos: NST 2 v/semana o CST semanal o
PBF semanal
36 semanas Estimacion del peso fetal por ECO
37 - 38.5
semanas
Amniocentesis & Parto para pacientes con pobre
control
38.5 - 40
semanas
Parto c/s amniocentesis para pacientes con buen
control
NST, CST, Perfil BF Fetal, ECO seriada, Doppler, Crecimiento Fetal,
Movimientos Fetales
54
-
Contraindicados
Sulfonilureas de Primera Generacin: atraviesan la placenta
Estimulan el crecimiento fetal del pncreas
Hiperinsulinemia fetal y teratogenicidad
Antidiabticos orales en la DG
55
-
Metformina
Disminuye incidencia ictericia neonatal y de la morbilidad
infantil
Incidencia de GEG fue de 15% en el grupo de metformina, 27%
entre los usuarios glibenclamida, 33% para la terapia
combinada, y 41% de insulina
Tratamiento de primera lnea para las mujeres con SOP (PCOS)
No teratognico
Reduce el riesgo de aborto en el primer trimestre
Uso preoeconcepcional reduce la incidencia de Diabetes
Gestacional de 31 % a 3 %
No hay resultados adversos del embarazo con el uso de
metformina
56
-
Cuidados Anteparto de la DG
Asesoramiento diettico
Monitorizacin de la glucosa (5 veces por da)
Terapia de insulina si es necesario (Agentes Hipoglucemiantes
orales)
Frecuente control de la glucosa
Monitoreo Ecogrfico del crecimiento fetal
Modo de Parto: Basado en los problemas obsttricos
Momento de la entrega: Basada en el control de la glucosa
57
-
Manejo Intraparto
Requisitos absolutos:
Dextrosa contenida en lquidos por va intravenosa
Insulina
Control de la glucosa por hora
Monitoreo Continuo de la frecuencia cardaca fetal
Tocodinanometra continua
Manejo de la labor en forma normal. Va ms disponible
58
-
Indicaciones para el parto en gestantes
diabticas
Tipo Indicacin
Fetal
NST no reactivo + CST Reactivo
Madurez fetal ms evidencia sonogrfica de
arresto en el crecimiento fetal
Disminucin del crecimiento fetal, disminucin
del lquido amnitico y 40 - 41 semanas
Materna
Preeclampsia Severa
Preeclampsia leve , feto maduro
Falla renal marcada
Obsttrica Labor Pretermino con toclisis fallada, feto
maduro, cervix inducible
59
-
Interrupcin del Embarazo
Control metablico adecuado: 40 - 41 sem
Tratamiento Insulina: Hospitalizar 38 semanas
Macrosoma, alteracin metablica 37 - 38 semanas
(madurez fetal)
Va de Parto: Cesrea si peso mayor de 4.5 kg
Puerperio normal sin restriccin de Carbohidratos
TTGO: Entre 6a y 7a. Semana Post parto
60
-
Diabetes Gestacional c / insulina
(induccin)
Suspender Insulina matinal
Glicemia basal y c/2hrs. (70 - 120 mg/dl)
Dextrosa 5% a 125 cc/hr
Insulina 5U/500 cc en Suero fisiolgico a 0.25 U/hr
Suspender Insulina Post parto
Post parto inmediato: Dextrosa 5% 125 a 200 cc/hr.
Post parto: Rgimen blando 50 - 60 gr. de carbohidratos
cada 6 horas. Insulina Post parto si glicemia es mayor a 180
mg/dl.
61
-
Cesrea electiva
A primera hora y suspender Insulina matinal
Dextrosa 5% a 125 cc / hr
Infusin continua de Insulina 0.5 - 1 U / hr
Mantener glicemia 70 a 120 mg / dl
Post parto sin Insulina, slo Dextrosa 5% 125 cc / hr por 24 horas
Rgimen comn lquido a las 12 horas post parto
Glicemia capilar (hipoglicemia post parto)
La noche antes de la ciruga: Tomar la dosis completa de NPH o
gliburida. No aplicarse la dosis matinal de insulina o gliburida
62
-
Manejo en el Post - Parto
Dosis usual de insulina es 30 50% menor
Solo usar Monitoreos de glicemia para pacientes con DG
Objetivo en posparto inmediato: tener glicemia digital < 200
Para DG: repetir TTG 75 g a las 6 semanas despus del parto
Para DG: Riesgo a largo plazo de la DM
Anticoncepcin
Acido Flico: 0.4 mg. ARO: 4 mg/d )disminuir riesgo de Defectos
del Tubo Neural)
Aumento del riesgo de la obesidad y de tolerancia anormal a la
glucosa
17 - 63 % de riesgo de hacer diabetes no gestacional dentro de 5
a 16 aos despus de la DG, segn los factores de riesgo
63
-
64
-
Revisin de los medicamentos para la
Diabetes despus del parto
Ajustar la insulina en pacientes con diabetes tipo 1 pre
gestacional despus del parto de acuerdo con las mltiples
pruebas diarias de glucosa en sangre para mantener la
hemoglobina A1c a < 7%
Detener la insulina en mujeres con DG despus del parto y
monitorear los niveles de glucosa
Considerar la reinstauracin de la medicacin oral para la
diabetes en las mujeres con diabetes tipo 2 despus del parto
a menos que el paciente est amamantando
65
-
Consejera a todas las MEF Obesas sobre la
necesidad de Planificacin Familiar
Asegurar el control de natalidad efectivo en todo momento, a
menos que el paciente est tratando de concebir y se encuentra
en un buen control diabtico
Aconsejar a las mujeres con diabetes tipo 1 o tipo 2 de los
riesgos de malformacin fetal en los embarazos no planificados
y con mal control metablico
Lograr el ayuno niveles de glucosa de 70 a 100 mg / dl y los
niveles postprandiales (2 horas) de < 140 mg / dl en las mujeres
diabticas que planeen quedar embarazadas
66
-
Consejera a todas las mujeres obesas en edad
frtil sobre la necesidad de la dieta y el ejercicio
para disminuir el riesgo de DG
Proporcionar asesoramiento nutricional para las MEF obesas,
en consonancia con la Asociacin Americana de Diabetes
Recomendar a las mujeres obesas que estn planeando
quedarse embarazadas o ya esten embarazadas:
Restriccin 30% - 33% de caloras si su IMC > 30
Limitar consumo de grasas a < 30% de las caloras
Incrementar su actividad fsica, tal como se recomienda fuera
embarazo, o un programa de ejercicio moderado si la mujer ya
est embarazada
67
-
Plan para las gestaciones futuras
Recomendar un mtodo anticonceptivo inmediatamente
despus del parto
Haga hincapi en la importancia del asesoramiento
previo a la concepcin
68
-
Despus del parto, clasificar a los pacientes
que se encontraron diabticos durante el
embarazo y hacer planes de seguimiento a
largo plazo
Continuar en casa el monitoreo de la glucosa en las mujeres
que resultaron con DG por lo menos 6 semanas despus del
parto para determinar si tienen una diabetes tipo 1 o 2, o si su
hiperglucemia se resolvi
Asesorar a los pacientes con DG en la necesidad a largo
plazo para descartar diabetes
Recomendar nutricin y ejercicios consistentes con la
Asociacin Americana de Diabetes para los pacientes con
hiperglucemia transitoria del embarazo y despus del parto
69
-
70
-
Diabet Med. 2011 Aug;28(8):900-5. doi: 10.1111/j.1464-
5491.2011.03291.x. A meta - analysis of the association between pre-
eclampsia and childhood-onset Type 1 diabetes mellitus. Henry
EB, Patterson CC, Cardwell CR.
Data were available from 16 studies including 8315 children with Type
1 diabetes
Overall, there was little evidence of an increase in
the risk of Type 1 diabetes in children born to
mothers who had pre-eclampsia
during pregnancy (OR = 1.10, 95% CI 0.96-1.27; P = 0.17)
This association did not vary much between studies (I(2) = 28%, P for
heterogeneity =0.14). The association was similar in three cohort
studies (OR = 1.05, 95% CI 0.77-1.44; P = 0.75) and in seven studies with
a low risk of bias (OR = 1.13, 95% CI 0.91-1.40; P = 0.27), but was more
marked in 13 studies which ascertained pre-eclampsia from obstetrical
records or birth registry data (OR = 1.18, 95% CI 1.03-1.36; P = 0.02)
71
http://www.ncbi.nlm.nih.gov/pubmed/21418091http://www.ncbi.nlm.nih.gov/pubmed/21418091http://www.ncbi.nlm.nih.gov/pubmed/21418091http://www.ncbi.nlm.nih.gov/pubmed/21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Henry EB[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Henry EB[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Henry EB[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Patterson CC[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Patterson CC[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Patterson CC[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Cardwell CR[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Cardwell CR[Author]&cauthor=true&cauthor_uid=21418091http://www.ncbi.nlm.nih.gov/pubmed?term=Cardwell CR[Author]&cauthor=true&cauthor_uid=21418091
-
Conclusions
This analysis demonstrates little evidence of any substantial
increase in childhood Type 1 diabetes risk after pregnancy
complicated by pre - eclampsia
72
-
Diabetologia. 2008 May;51(5):726-35. doi: 10.1007/s00125-008-0941-z.
Epub 2008 Feb 22. Caesarean section is associated with an increased
risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of
observational studies. Cardwell CR, Stene LC,
Twenty studies were identified. Overall, there was a significant
increase in the risk of type 1 diabetes in children born by Caesarean
section (OR 1.23, 95% CI 1.15-1.32, p < 0.001)
There was little evidence of heterogeneity between studies (p = 0.54).
Seventeen authors provided raw data or adjusted estimates to facilitate
adjustments for potential confounders
In these studies, there was evidence of an increase in diabetes risk
with greater birth weight, shorter gestation and greater maternal age
The increased risk of type 1 diabetes after Caesarean section was little
altered after adjustment for gestational age, birth weight, maternal age,
birth order, breast-feeding and maternal diabetes (adjusted OR 1.19,
95% CI 1.04-1.36, p = 0.01)
73
http://www.ncbi.nlm.nih.gov/pubmed/18292986http://www.ncbi.nlm.nih.gov/pubmed/18292986http://www.ncbi.nlm.nih.gov/pubmed?term=Cardwell CR[Author]&cauthor=true&cauthor_uid=18292986http://www.ncbi.nlm.nih.gov/pubmed?term=Cardwell CR[Author]&cauthor=true&cauthor_uid=18292986http://www.ncbi.nlm.nih.gov/pubmed?term=Cardwell CR[Author]&cauthor=true&cauthor_uid=18292986http://www.ncbi.nlm.nih.gov/pubmed?term=Stene LC[Author]&cauthor=true&cauthor_uid=18292986http://www.ncbi.nlm.nih.gov/pubmed?term=Stene LC[Author]&cauthor=true&cauthor_uid=18292986http://www.ncbi.nlm.nih.gov/pubmed?term=Stene LC[Author]&cauthor=true&cauthor_uid=18292986
-
Conclusions
This analysis demonstrates a 20% increase in the risk of childhood-
onset type 1 diabetes after Caesarean section delivery that cannot
be explained by known confounders
74
-
NICE clinical guidelines Issued: March 2008 (last modified: July 2008) CG63
Diabetes in pregnancy: Management of diabetes and its complications from
pre - conception to the postnatal period
Diabetes is a disorder of carbohydrate metabolism that requires immediate
changes in lifestyle
In its chronic forms, diabetes is associated with long-term vascular
complications, including retinopathy, nephropathy, neuropathy and vascular
disease
650,000 women give birth in England and Wales each year, and 2 5% of
pregnancies involve women with diabetes
Approximately 87.5% of pregnancies complicated by diabetes are
estimated to be due to gestational diabetes (which may or may not resolve
after pregnancy), with 7.5% being due to type 1 diabetes and the remaining
5% being due to type 2 diabetes
75
-
The prevalence of type 1 and type 2 diabetes is increasing.
In particular, type 2 diabetes is increasing in certain minority
ethnic groups (including people of African, black Caribbean, South
Asian, Middle Eastern and Chinese family origin)
Diabetes in pregnancy is associated with risks to the woman and
to the developing fetus
Miscarriage, pre - eclampsia and preterm labour are more common
in women with pre-existing diabetes
In addition, diabetic retinopathy can worsen rapidly during
pregnancy
Stillbirth, congenital malformations, macrosomia, birth injury,
perinatal mortality and postnatal adaptation problems (such as
hypoglycaemia) are more common in babies born to women with
pre-existing diabetes
76
-
Cochrane Database Syst Rev. 2008 Apr 16;(2):CD006674. doi:
10.1002/14651858.CD006674.pub2.. Dietary advice in pregnancy for preventing
gestational diabetes mellitus. Tieu J, Crowther CA, Middleton P.
Gestational diabetes mellitus (GDM) is a form of diabetes that occurs
during pregnancy which can result in significant adverse outcomes for mother
and child both in the short and long term. The potential for adverse outcomes, in
addition to the increasing prevalence of gestational diabetes worldwide,
demonstrates the need to assess strategies, such as dietary advice, that might
prevent gestational diabetes.
Three trials (107 women) were included in the review. One trial (25 pregnant
women) analysed high - fibre diets with no included outcomes showing
statistically significant differences. Two trials (82 pregnant women) assessed low
glycaemic index (LGI) versus high glycaemic index diets for pregnant women.
Women on the LGI diet had fewer large for gestational age infants (one trial;
relative risk (RR) 0.09, 95% confidence interval (CI) 0.01 to 0.69), infants with
lower ponderal indexes (two trials; weighted mean difference (WMD) -0.18, 95%
CI -0.32 to -0.04, random-effects analysis) and lower maternal fasting glucose
levels (two trials; WMD -0.28 mmol/L 95% CI -0.54 to -0.02, random-effects model).
Results for women on the LGI diet on neonatal birth weight were not conclusive
under a random-effects model (two trials; WMD -527.64 g, 95% CI -1119.20 to
63.92); however, on a fixed-effect model, women on the LGI diet gave birth to
lighter babies (two trials; WMD -445.55 g, 95% CI -634.16 to -256.95). High
heterogeneity was observed between the trials in most results and both were
relatively small trials. One of these trials also included a standard exercise
regimen for all participants.
77
http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed/18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Tieu J[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Tieu J[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Tieu J[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Crowther CA[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Crowther CA[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Crowther CA[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=18425961http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=18425961
-
Conclusions
While a low glycaemic index diet was seen to be beneficial for
some outcomes for both mother and child, results from the
review were inconclusive
Further trials with large sample sizes and longer follow up are
required to make more definitive conclusions
No conclusions could be drawn from the high - fibre versus
control - diet comparison since the trial involved did not report
on many of the outcomes we prespecified
78
-
BMC Public Health. 2011 Apr 13;11 Suppl 3:S2. doi: 10.1186/1471-2458-11-
S3-S2. Effect of screening and management of diabetes during pregnancy on
stillbirths. Syed M, Javed H, Yakoob MY, Bhutta ZA.
A total of 70 studies were selected for data extraction including fourteen intervention
studies and fifty six observational studies. No randomized controlled trials were
identified evaluating early detection of diabetes mellitus in pregnancy versus standard
screening (glucose challenge test between 24th to 28th week of gestation)
in pregnancy.
Intensive management of gestational diabetes (including specialized dietary advice,
increased monitoring and tailored dietary therapy) during pregnancy (3 studies: 3791
participants) versus conventional management (dietary advice and insulin as required)
was associated with a non-significant reduction in the risk of stillbirths (RR 0.20; 95%
CI: 0.03-1.10) ('moderate' quality evidence)
Optimal control of serum blood glucose versus sub-optimal control was associated
with a significant reduction in the risk of perinatal mortality (2 studies, 5286
participants: RR = 0.40, 95% CI 0.25- 0.63), but not stillbirths (3 studies, 2469
participants: RR = 0.51, 95% CI 0.14-1.88). Preconception care of diabetes (information
about need for optimization of glycemic control before pregnancy, assessment
of diabetes complications, review of dietary habits, intensification of capillary blood
glucose self-monitoring and optimization of insulin therapy) versus none (3 studies: 910
participants) was associated with a reduction in perinatal mortality (RR = 0.29, 95% CI
0.14 -0.60). Using the Delphi process for estimating effect size of
optimal diabetes recognition and management yielded a median effect size of 10%
reduction in stillbirths
79
http://www.ncbi.nlm.nih.gov/pubmed/21501437http://www.ncbi.nlm.nih.gov/pubmed/21501437http://www.ncbi.nlm.nih.gov/pubmed/21501437http://www.ncbi.nlm.nih.gov/pubmed/21501437http://www.ncbi.nlm.nih.gov/pubmed/21501437http://www.ncbi.nlm.nih.gov/pubmed/21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Syed M[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Syed M[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Syed M[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Javed H[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Javed H[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Javed H[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Yakoob MY[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Yakoob MY[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Yakoob MY[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Bhutta ZA[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Bhutta ZA[Author]&cauthor=true&cauthor_uid=21501437http://www.ncbi.nlm.nih.gov/pubmed?term=Bhutta ZA[Author]&cauthor=true&cauthor_uid=21501437
-
Conclusions
Diabetes, especially pre-gestational diabetes with its attendant
vascular complications, is a significant risk factor for stillbirth and
perinatal death
Our review highlights the fact that very few studies of adequate
quality are available that can provide estimates of the effect of
screening for aid management of diabetes in pregnancy on stillbirth
risk
Using the Delphi process we recommend a conservative 10%
reduction in the risk of stillbirths, as a point estimate for inclusion
in the LiST.
80
-
BMJ. 2010 Apr 1;340:c1395. doi: 10.1136/bmj.c1395. Effects of treatment in
women with gestational diabetes mellitus: systematic review and meta-
analysis. Horvath K, Koch K, Jeitler K, Matyas E, Bender R, Bastian H, Lange
S, Siebenhofer A.
Five randomised controlled trials matched the inclusion criteria for specific
versus usual treatment. All studies used a two step approach with a 50 g
glucose challenge test or screening for risk factors, or both, and a
subsequent 75 g or 100 g oral glucose tolerance test
Meta-analyses did not show significant differences for most single end
points judged to be of direct clinical importance
In women specifically treated for gestational diabetes, shoulder dystocia
was significantly less common (odds ratio 0.40, 95% confidence interval 0.21
to 0.75), and one randomised controlled trial reported a significant reduction
of pre-eclampsia (2.5 v 5.5%, P=0.02)
For the surrogate end point of large for gestational age infants, the odds
ratio was 0.48 (0.38 to 0.62). In the 13 randomised controlled trials of
different intensities of specific treatments, meta-analysis showed a
significant reduction of shoulder dystocia in women with more intensive
treatment (0.31, 0.14 to 0.70).
81
http://www.ncbi.nlm.nih.gov/pubmed/20360215http://www.ncbi.nlm.nih.gov/pubmed/20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Horvath K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Horvath K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Horvath K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Koch K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Koch K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Koch K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Jeitler K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Jeitler K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Jeitler K[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Matyas E[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Matyas E[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Matyas E[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Bender R[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Bender R[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Bender R[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Bastian H[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Bastian H[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Bastian H[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Lange S[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Lange S[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Lange S[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Siebenhofer A[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Siebenhofer A[Author]&cauthor=true&cauthor_uid=20360215http://www.ncbi.nlm.nih.gov/pubmed?term=Siebenhofer A[Author]&cauthor=true&cauthor_uid=20360215
-
Conclusions
Treatment for gestational diabetes, consisting of treatment to
lower blood glucose concentration alone or with special
obstetric care, seems to lower the risk for some perinatal
complications
Decisions regarding treatment should take into account that the
evidence of benefit is derived from trials for which women were
selected with a two step strategy (glucose challenge
test/screening for risk factors and oral glucose tolerance test)
82
-
Cochrane Database Syst Rev. 2012 Jul 11;7:CD009021. doi:
10.1002/14651858.CD009021.pub2. Exercise for pregnant women for preventing
gestational diabetes mellitus. Han S, Middleton P, Crowther CA.
We included five trials with a total of 1115 women and their babies (922 women and their
babies contributed outcome data). Four of the five included trials had small sample sizes
with one large trial that recruited 855 women and babies. All five included trials had a
moderate risk of bias. When comparing women receiving additional exercise interventions
with those having routine antenatal care, there was no significant difference in GDM
incidence (three trials, 826 women, risk ratio (RR) 1.10, 95% confidence interval (CI) 0.66 to
1.84), caesarean section (two trials, 934 women, RR 1.33, 95% CI 0.97 to 1.84) or operative
vaginal birth (two trials, 934 women, RR 0.83, 95% CI 0.58 to 1.17)
No trial reported the infant primary outcomes prespecified in the review. None of the five
included trials found significant differences in insulin sensitivity. Evidence from one single
large trial suggested no significant difference in the incidence of
developing pregnancy hyperglycaemia not meeting GDM diagnostic criteria, pre-eclampsia or
admission to neonatal ward between the two study groups
Babies born to women receiving exercise interventions had a non-significant trend to a lower
ponderal index (mean difference (MD) -0.08 gram x 100 m(3), 95% CI -0.18 to 0.02, one trial,
84 infants)
No significant differences were seen between the two study groups for the outcomes of birth
weight (two trials, 167 infants, MD -102.87 grams, 95% CI -235.34 to 29.60), macrosomia (two
trials, 934 infants, RR 0.91, 95% CI 0.68 to 1.22), or small-for-gestational age (one trial, 84
infants, RR 1.05, 95% CI 0.25 to 4.40) or gestational age at birth (two trials, 167 infants, MD -
0.04 weeks, 95% CI -0.37 to 0.29) or Apgar score less than seven at five minutes (two trials,
919 infants, RR 1.00, 95% CI 0.27 to 3.65).
None of the trials reported long-term outcomes for women and their babies
No information was available on health services costs.
83
http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed/22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Han S[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Han S[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Han S[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Crowther CA[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Crowther CA[Author]&cauthor=true&cauthor_uid=22786521http://www.ncbi.nlm.nih.gov/pubmed?term=Crowther CA[Author]&cauthor=true&cauthor_uid=22786521
-
Conclusions
There is limited randomised controlled trial evidence available on the
effect of exercise during pregnancy for preventing pregnancy glucose
intolerance or GDM
Results from three randomised trials with moderate risk of bias
suggested no significant difference in GDM incidence between women
receiving an additional exercise intervention and routine care
Based on the limited data currently available, conclusive evidence is not
available to guide practice
84
-
J Womens Health (Larchmt). 2011 Oct;20(10):1551-63. doi:
10.1089/jwh.2010.2703. Epub 2011 Aug 12. Interventions for preventing
gestational diabetes mellitus: a systematic review and meta - analysis.
Oostdam N, van Poppel MN, Wouters MG, van Mechelen W.
Nineteen studies evaluating six types of interventions were included.
Dietary counseling significantly reduced GDM incidence compared to
standard care
None of the interventions was effective in lowering maternal fasting blood
glucose
Low glycemic index (LGI) diet advice and an exercise program significantly
reduced the risk of macrosomia
The quality of evidence for these outcomes was low
85
http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed/21838525http://www.ncbi.nlm.nih.gov/pubmed?term=Oostdam N[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=Oostdam N[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=Oostdam N[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Poppel MN[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Poppel MN[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Poppel MN[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Poppel MN[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Poppel MN[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=Wouters MG[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=Wouters MG[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=Wouters MG[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Mechelen W[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Mechelen W[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Mechelen W[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Mechelen W[Author]&cauthor=true&cauthor_uid=21838525http://www.ncbi.nlm.nih.gov/pubmed?term=van Mechelen W[Author]&cauthor=true&cauthor_uid=21838525
-
Conclusions
The results indicate that there may be some benefits of dietary
counseling, an LGI diet advice, or an exercise program
However, better-designed studies are required to generate higher
quality evidence
At the moment, no strong conclusions can be drawn with regard to
the best intervention for prevention of GDM
86
-
Am J Kidney Dis. 2010 Jun;55(6):1026-39. doi: 10.1053/j.ajkd.2009.12.036.
Epub 2010 Mar 25. Kidney disease after preeclampsia: a systematic review
and meta-analysis. McDonald SD, Han Z, Walsh MW, Gerstein
HC, Devereaux PJ.
7 cohort studies were included, involving 273 patients with preeclampsia
and 333 patients with uncomplicated pregnancies
At a weighted mean of 7.1 years postpartum, 31% of women with a history
of preeclampsia had microalbuminuria compared with 7% of women with
uncomplicated pregnancies, a 4 - fold increased risk, whereas women with
severe preeclampsia had an 8 - fold increase
Serum creatinine level and estimated glomerular filtration rate were not
significantly different at follow-up in women with and without
preeclampsia, making it unlikely that they would have been different at
baseline
87
http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed/20346562http://www.ncbi.nlm.nih.gov/pubmed?term=McDonald SD[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=McDonald SD[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=McDonald SD[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Han Z[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Han Z[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Han Z[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Walsh MW[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Walsh MW[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Walsh MW[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Gerstein HC[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Gerstein HC[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Gerstein HC[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Devereaux PJ[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Devereaux PJ[Author]&cauthor=true&cauthor_uid=20346562http://www.ncbi.nlm.nih.gov/pubmed?term=Devereaux PJ[Author]&cauthor=true&cauthor_uid=20346562
-
Conclusion
Women with a history of preeclampsia have an increased risk of
microalbuminuria with a prevalence similar to the published
prevalence in patients with type 1 diabetes mellitus
Further research is needed to determine whether the increased risk
of microalbuminuria persists after adjustment for a thorough set of
confounding factors in larger populations and the mechanisms
underlying this association
88
-
Diabetes Metab Res Rev. 2012 Mar;28(3):252-7. doi: 10.1002/dmrr.1304.
Major congenital malformations in women with
gestational diabetes mellitus: a systematic review and meta-analysis.
Balsells M, Garca-Patterson A, Gich I, Corcoy R.
Two case control and 15 cohort studies were selected out of 3488
retrieved abstracts
A higher risk of major congenital malformations was observed in
offspring of women with gestational diabetes with the following relative
risk (RR)/odds ratios (OR) and 95% confidence intervals (CI): RR 1.16
(1.07-1.25) in cohort studies and OR 1.4 (1.22-1.62) in case control
studies
Risk of major congenital malformations was much higher in offspring of
women with PGDM than in those of the reference group: RR 2.66 (2.04-
3.47) in cohort studies and OR 4.7 (3.01-6.95) in the single case control
study providing information.
89
http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed/22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Balsells M[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Balsells M[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Balsells M[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Gich I[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Gich I[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Gich I[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Corcoy R[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Corcoy R[Author]&cauthor=true&cauthor_uid=22052679http://www.ncbi.nlm.nih.gov/pubmed?term=Corcoy R[Author]&cauthor=true&cauthor_uid=22052679
-
Conclusion
There is a slightly higher risk of major congenital malformations
in women with gestational diabetes than in the reference group
The contribution of women with overt hyperglycemia and other
factors could not be ascertained
This risk, however, is much lower than in women with
pregestational diabetes
90
-
Lancet. 2011 Apr 16;377(9774):1331-40. doi: 10.1016/S0140-6736(10)62233-7.
Major risk factors for stillbirth in high-income countries: a systematic review
and meta-analysis. Flenady V, Koopmans L, Middleton P, Fren JF, Smith
GC, Gibbons K, Coory M, Gordon A, Ellwood D, McIntyre HD, Fretts R, Ezzati M.
Of 6963 studies initially identified, 96 population-based studies were included.
Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest
ranking modifiable risk factor, with PARs of 8-18% across the five countries and
contributing to around 8000 stillbirths (22 weeks' gestation) annually across all
high-income countries
Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11%
and 4-7%, respectively, and each year contribute to more than 4200 and 2800
stillbirths, respectively, across all high-income countries
In disadvantaged populations maternal smoking could contribute to 20% of
stillbirths
Primiparity contributes to around 15% of stillbirths
Of the pregnancy disorders, small size for gestational age and abruption are the
highest PARs (23% and 15%, respectively), which highlights the notable role of
placental pathology in stillbirth
Pre-existing diabetes and hypertension remain important contributors to stillbirth
in such countries
91
http://www.ncbi.nlm.nih.gov/pubmed/21496916http://www.ncbi.nlm.nih.gov/pubmed/21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Flenady V[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Flenady V[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Flenady V[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Koopmans L[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Koopmans L[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Koopmans L[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Middleton P[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Fr%C3%B8en JF[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Fr%C3%B8en JF[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Fr%C3%B8en JF[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Smith GC[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Smith GC[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Smith GC[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Gibbons K[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Gibbons K[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Gibbons K[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Coory M[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Coory M[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Coory M[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Gordon A[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Gordon A[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Gordon A[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Ellwood D[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Ellwood D[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Ellwood D[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=McIntyre HD[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=McIntyre HD[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=McIntyre HD[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Fretts R[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Fretts R[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Fretts R[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Ezzati M[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Ezzati M[Author]&cauthor=true&cauthor_uid=21496916http://www.ncbi.nlm.nih.gov/pubmed?term=Ezzati M[Author]&cauthor=true&cauthor_uid=21496916
-
J Clin Endocrinol Metab. 2009 Nov;94(11):4284-91. doi: 10.1210/jc.2009-
1231. Epub 2009 Oct 6. Maternal and fetal outcome in women with type
2 versus type 1 diabetes mellitus: a systematic review and
metaanalysis. Balsells M, Garca-Patterson A, Gich I, Corcoy R.
Thirty-three studies qualified for inclusion of 3743 citations retrieved
Women with type 2 DM had lower glycated hemoglobin (HbA1c) at
booking and throughout pregnancy but a higher risk of perinatal
mortality [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.15-1.96]
without significant differences in the rates of major congenital
malformations, stillbirth, and neonatal mortality
As to secondary outcomes, women with type 2 DM had less diabetic
ketoacidosis (OR 0.09, 95% CI 0.02-0.34) and cesarean section (OR
0.80, 95% CI 0.59-0.94) without differences in other outcomes
92
http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed/19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Balsells M[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Balsells M[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Balsells M[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Garc%C3%ADa-Patterson A[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Gich I[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Gich I[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Gich I[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Corcoy R[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Corcoy R[Author]&cauthor=true&cauthor_uid=19808847http://www.ncbi.nlm.nih.gov/pubmed?term=Corcoy R[Author]&cauthor=true&cauthor_uid=19808847
-
Conclusions
Despite a milder glycemic disturbance, women with type 2 DM had
no better perinatal outcomes than those with type 1, indicating that
type 2 DM in pregnancy is a serious condition
93
-
Am J Obstet Gynecol. 2010 Nov;203(5):457.e1-9. doi:
10.1016/j.ajog.2010.06.044. Epub 2010 Aug 24. Oral hypoglycemic
agents vs insulin in management of gestational diabetes: a systematic
review and metaanalysis. Dhulkotia JS, Ola B, Fraser R, Farrell T.
Six studies comprising 1388 subjects were analyzed
No significant differences were found in maternal fasting (weighted
mean difference [WMD], 1.31; 95% confidence interval [CI], 0.81-3.43) or
postprandial (WMD, 0.80; 95% CI, -3.26 to 4.87) glycemic control
Use of oral hypoglycemic agents (OHAs) was not associated with risk of
neonatal hypoglycemia (odds ratio [OR], 1.59; 95% CI, 0.70-3.62),
increased birthweight (WMD, 56.11; 95% CI, -42.62 to 154.84), incidence
of caesarean section (OR, 0.91; 95% CI, -0.68 to 1.22), or incidence of
large-for-gestational-age babies (OR, 1.01; 95% CI, 0.61-1.68).
94
http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed/20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Dhulkotia JS[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Dhulkotia JS[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Dhulkotia JS[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Ola B[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Ola B[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Ola B[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Fraser R[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Fraser R[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Fraser R[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Farrell T[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Farrell T[Author]&cauthor=true&cauthor_uid=20739011http://www.ncbi.nlm.nih.gov/pubmed?term=Farrell T[Author]&cauthor=true&cauthor_uid=20739011
-
Conclusion
Our study demonstrates that there are no differences in glycemic
control or pregnancy outcomes when OHAs were compared with
insulin
95
-
Diabetes Care. 2011 Jan;34(1):223-9. doi: 10.2337/dc10-1368. Epub 2010
Sep 27. Physical activity before and during pregnancy and risk of
gestational diabetes mellitus: a meta-analysis. Tobias DK, Zhang C, van
Dam RM, Bowers K, Hu FB.
Our search identified seven pre - pregnancy and five
early pregnancy studies, including five prospective cohorts, two
retrospective case-control studies, and two cross-sectional study
designs
Pre - pregnancy physical activity was assessed in 34,929 total
participants, which included 2,813 cases of GDM, giving a pooled odds
ratio (OR) of 0.45 (95% CI 0.28-0.75) when the highest versus lowest
categories were compared
Exercise in early pregnancy was assessed in 4,401 total participants,
which included 361 cases of GDM, and was also significantly protective
(0.76 [95% CI 0.70-0.83]).
96
http://www.ncbi.nlm.nih.gov/pubmed/20876206http://www.ncbi.nlm.nih.gov/pubmed/20876206http://www.ncbi.nlm.nih.gov/pubmed/20876206http://www.ncbi.nlm.nih.gov/pubmed/20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Tobias DK[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Tobias DK[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Tobias DK[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Zhang C[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Zhang C[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Zhang C[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=van Dam RM[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=van Dam RM[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=van Dam RM[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=van Dam RM[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=van Dam RM[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Bowers K[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Bowers K[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Bowers K[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Hu FB[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Hu FB[Author]&cauthor=true&cauthor_uid=20876206http://www.ncbi.nlm.nih.gov/pubmed?term=Hu FB[Author]&cauthor=true&cauthor_uid=20876206
-
Conclusions
Higher levels of physical activity before pregnancy or in
early pregnancy are associated with a significantly lower risk of
developing GDM
97
-
BMC Pregnancy Childbirth. 2010 Oct 14;10:63. doi: 10.1186/1471-2393-
10-63. Preconception care for diabetic women for improving maternal
and fetal outcomes: a systematic review and meta-analysis. Wahabi
HA, Alzeidan RA, Bawazeer GA, Alansari LA, Esmaeil SA.
Meta - analysis suggested that preconception care is effective in
reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17
(95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8
(95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT =
32 (95% CI 19-109)
Preconception care lowers HbA1c in the first trimester of pregnancy by
an average of 2.43% (95% CI 2.27-2.58)
Women who received preconception care booked earlier for antenatal
care by an average of 1.32 weeks (95% CI 1.23-1.40).
98
http://www.ncbi.nlm.nih.gov/pubmed/20946676http://www.ncbi.nlm.nih.gov/pubmed/20946676http://www.ncbi.nlm.nih.gov/pubmed/20946676http://www.ncbi.nlm.nih.gov/pubmed/20946676http://www.ncbi.nlm.nih.gov/pubmed/20946676http://www.ncbi.nlm.nih.gov/pubmed/20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Wahabi HA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Wahabi HA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Wahabi HA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Alzeidan RA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Alzeidan RA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Alzeidan RA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Bawazeer GA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Bawazeer GA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Bawazeer GA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Alansari LA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Alansari LA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Alansari LA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Esmaeil SA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Esmaeil SA[Author]&cauthor=true&cauthor_uid=20946676http://www.ncbi.nlm.nih.gov/pubmed?term=Esmaeil SA[Author]&cauthor=true&cauthor_uid=20946676
-
Conclusion
Preconception care is effective in reducing diabetes related
congenital malformations, preterm delivery and maternal
hyperglycemia in the first trimester of pregnancy
99
-
Obes Rev. 2009 Mar;10(2):194-203. doi: 10.1111/j.1467-789X.2008.00541.x.
Epub 2008 Nov 24. Prepregnancy BMI and the risk of gestational diabetes: a
systematic review of the literature with meta-analysis. Torloni MR, Betrn
AP, Horta BL, Nakamura MU, Atallah AN, Moron AF, Valente O.
The objective of this study is to assess and quantify the risk for
gestational diabetes mellitus (GDM) according to prepregnancy maternal body mass
index (BMI)
The design is a systematic review of observational studies published in the last 30
years. Four electronic databases were searched for publications (1977-2007)
BMI was elected as the only measure of obesity, and all diagnostic criteria for GDM
were accepted. Studies with selective screening for GDM were excluded. There were
no language restrictions. The methodological quality of primary studies was assessed.
Some 1745 citations were screened, and 70 studies (two unpublished) involving 671
945 women were included (59 cohorts and 11 case-controls). Most studies were of
high or medium quality. Compared with women with a normal BMI, the unadjusted
pooled odds ratio (OR) of an underweight woman developing GDM was 0.75 (95%
confidence interval [CI] 0.69 to 0.82). The OR for overweight, moderately obese and
morbidly obese women were 1.97 (95% CI 1.77 to 2.19), 3.01 (95% CI 2.34 to 3.87) and
5.55 (95% CI 4.27 to 7.21) respectively
For every 1 kg m(-2) increase in BMI, the prevalence of GDM increased by 0.92% (95%
CI 0.73 to 1.10). The risk of GDM is positively associated with prepregnancy BMI. This
information is important when counselling women planning a pregnancy.
100
http://www.ncbi.nlm.nih.gov/pubmed/19055539http://www.ncbi.nlm.nih.gov/pubmed/19055539http://www.ncbi.nlm.nih.gov/pubmed/19055539http://www.ncbi.nlm.nih.gov/pubmed/19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Torloni MR[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Torloni MR[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Torloni MR[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Betr%C3%A1n AP[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Betr%C3%A1n AP[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Betr%C3%A1n AP[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Horta BL[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Horta BL[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Horta BL[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Nakamura MU[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Nakamura MU[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Nakamura MU[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Atallah AN[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Atallah AN[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Atallah AN[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Moron AF[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Moron AF[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Moron AF[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Valente O[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Valente O[Author]&cauthor=true&cauthor_uid=19055539http://www.ncbi.nlm.nih.gov/pubmed?term=Valente O[Author]&cauthor=true&cauthor_uid=19055539
-
BMC Pregnancy Childbirth. 2009 May 7;9 Suppl 1:S5. doi: 10.1186/1471-2393-
9-S1-S5. Reducing stillbirths: screening and monitoring
during pregnancy and labour. Haws RA, Yakoob MY, Soomro T, Menezes
EV, Darmstadt GL, Bhutta ZA.
We found a dearth of rigorous evidence of direct impact of any of these
screening procedures and interventions on stillbirth incidence
Observational studies testing some interventions, including fetal movement
monitoring and Doppler monitoring, showed some evidence of impact on
stillbirths in selected high-risk populations, but require larger rigourous
trials to confirm impact
Other interventions, such as amniotic fluid assessment for oligohydramnios,
appear predictive of stillbirth risk, but studies are lacking which assess the
impact on perinatal mortality of subsequent intervention based on test
findings
Few rigorous studies of cardiotocography have reported stillbirth outcomes,
but steep declines in stillbirth rates have been observed in high-income
settings such as the U.S., where cardiotocography is used in conjunction
with Caesarean section for fetal distress
101
http://www.ncbi.nlm.nih.gov/pubmed/19426468http://www.ncbi.nlm.nih.gov/pubmed/19426468http://www.ncbi.nlm.nih.gov/pubmed/19426468http://www.ncbi.nlm.nih.gov/pubmed/19426468http://www.ncbi.nlm.nih.gov/pubmed/19426468http://www.ncbi.nlm.nih.gov/pubmed/19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Haws RA[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Haws RA[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Haws RA[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Yakoob MY[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Yakoob MY[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Yakoob MY[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Soomro T[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Soomro T[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Soomro T[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Menezes EV[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Menezes EV[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Menezes EV[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Darmstadt GL[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Darmstadt GL[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Darmstadt GL[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Bhutta ZA[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Bhutta ZA[Author]&cauthor=true&cauthor_uid=19426468http://www.ncbi.nlm.nih.gov/pubmed?term=Bhutta ZA[Author]&cauthor=true&cauthor_uid=19426468
-
Conclusion
There are numerous research gaps and large, adequately controlled
trials are still needed for most of the interventions we considered
The impact of monitoring interventions on stillbirth relies on use of
effective and timely intervention should problems be detected.
Numerous studies indicated that positive tests were associated with
increased perinatal mortality, but while some tests had good sensitivity
in detecting distress, false-positive rates were high for most tests, and
questions remain about optimal timing, frequency, and implications of
testing
Few studies included assessments of impact of subsequent intervention
needed before recommending particular monitoring strategies as a
means to decrease stillbirth incidence
In high-income countries such as the US, observational evidence
suggests that widespread use of cardiotocography with Caesarean
section for fetal distress has led to significant declines in stillbirth
rates
Efforts to increase availability of Caesarean section in low-/middle-
income countries should be coupled with intrapartum monitoring
technologies where resources and provider skills permit
102
-
Cochrane Database Syst Rev. 2009 Jul 8;(3):CD003395. doi:
10.1002/14651858.CD003395.pub2. Treatments for gestational diabetes. Alwan
N, Tuffnell DJ, West J.
Eight randomised controlled trials (1418 women) were included.
Caesarean section rate was not significantly different when comparing any
specific treatment with routine antenatal care (ANC) including data from five
trials with 1255 participants (risk ratio (RR) 0.94, 95% confidence interval (CI)
0.80 to 1.12).
However, when comparing oral hypoglycaemics with insulin as treatment for
GDM, there was a significant reduction (RR 0.46, 95% CI 0.27 to 0.77, two trials,
90 participants).
There was a reduction in the risk of pre-eclampsia with intensive treatment
(including dietary advice and insulin) compared to routine ANC (RR 0.65, 95% CI
0.48 to 0.88, one trial, 1000 participants).
More women had their labours induced when given specific treatment compared
to routine ANC (RR 1.33, 95% CI 1.13 to 1.57, two trials, 1068 participants).
103
http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed/19588341http://www.ncbi.nlm.nih.gov/pubmed?term=Alwan N[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=Alwan N[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=Alwan N[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=Tuffnell DJ[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=Tuffnell DJ[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=Tuffnell DJ[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=West J[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=West J[Author]&cauthor=true&cauthor_uid=19588341http://www.ncbi.nlm.nih.gov/pubmed?term=West J[Author]&cauthor=true&cauthor_uid=19588341
-
The composite outcome of perinatal morbidity (death, shoulder
dystocia, bone fracture and nerve palsy) was significantly reduced for
those receiving intensive treatment for mild GDM compared to routine
ANC (RR 0.32, 95% CI 0.14 to 0.73, one trial, 1030 infants)
There was a reduction in the proportion of infants weighing more than
4000 grams (RR 0.46, 95% CI 0.34 to 0.63, one trial, 1030 infants) and
the proportion of infants weighing greater than the 90th birth centile
(RR 0.55, 95% CI 0.30 to 0.99, three trials, 223 infants) of mothers
receiving specific treatment for GDM compared to routine ANC
However, there was no statistically significant difference in this
proportion between infants of mothers receiving oral drugs compared to
insulin as treatment for GDM
104
-
Conclusions
S