-
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
