Diabetes mellitus e saúde materna durante a pandemia de covid-19 no Brasil / Diabetes mellitus and maternal health during the COVID-19 pandemic in Brazil / Diabetes mellitus y salud materna durante la pandemia de la COVID-19 en Brasil

A pandemia do novo coronavírus (covid-19) é um grave problema de saúde pública. Adicionalmente, a hiperglicemia na gestação (diabetes preexistente, diabetes diagnosticado pela primeira vez na gestação e diabetes mellitus gestacional) é uma das complicações maternas mais frequentes na população obstétrica. A sobreposição desses problemas pode refletir na saúde materna e fetal. Desse modo, o objetivo deste estudo é reunir evidências acerca da saúde materna de mulheres com hiperglicemia na gestação durante a pandemia de covid-19 no Brasil. Trata-se de uma revisão narrativa, em que a fonte de dados compreendeu artigos publicados até maio de 2023 nas bases de dados Medline, via PubMed, Lilacs e WHO COVID-19 Research Database. Foram listados 167 artigos e, após a aplicação dos critérios de elegibilidade, cinco estudos foram incluídos, compreendendo 1.469 gestantes e puérperas com diabetes mellitus gestacional ou diabetes preexistente. Quanto à saúde materna, os principais desfechos foram relacionados à infecção por covid-19, como gravidade da doença e risco de morte. Além disso, foi observada maior prevalência de transtornos mentais comuns, como ansiedade e depressão. Portanto, a saúde materna de mulheres com hiperglicemia na gestação foi impactada negativamente durante a pandemia de covid-19 no país.

The new coronavirus (COVID-19) pandemic is a major public health issue. Hyperglycemia during pregnancy (pre-existing diabetes, diabetes first diagnosed in pregnancy and gestational diabetes mellitus) is a frequent maternal complication in the obstetric population. Their overlap may impact maternal and fetal health. Thus, this narrative review gathered evidence on the maternal health of women with gestational hyperglycemia during the COVID-19 pandemic in Brazil. Articles published until May 2023 in the Medline (via PubMed), Lilacs and WHO COVID-19 Research Database online databases were eligible. Bibliographic search retrieved a total of 167 articles, of which five remained after applying the inclusion criteria, resulting in a sample of 1,469 pregnant and postpartum women with gestational diabetes or pre-existing diabetes. Regarding maternal health, the main outcomes were related to COVID-19 infection, such as disease severity and risk of death. Additionally, results showed a higher prevalence of common mental disorders such as anxiety and depression. In conclusion, the maternal health of women with gestational hyperglycemia was negatively impacted during the COVID-19 pandemic.

La pandemia del nuevo coronavirus (COVID-19) es un grave problema de salud pública. Además, la hiperglucemia durante el embarazo (diabetes preexistente, diabetes diagnosticada por primera vez durante el embarazo y diabetes mellitus gestacional) es una de las complicaciones maternas más frecuentes en la población obstétrica. La superposición de estos problemas puede afectar la salud materna y fetal. Por lo tanto, el objetivo de este estudio es recopilar evidencia sobre la salud materna de las mujeres con hiperglucemia en el embarazo durante la pandemia de la COVID-19 en Brasil. Se trata de una revisión narrativa, y la fuente de datos comprendió artículos publicados hasta mayo de 2023 en las bases de datos MEDLINE vía PubMed, LILACS y WHO COVID-19 Research Database. Se enumeró un total de 167 artículos y, después de aplicar los criterios de elegibilidad, se incluyeron cinco estudios con 1.469 mujeres embarazadas y puérperas con diabetes gestacional o diabetes preexistente. En cuanto a la salud materna, los principales resultados se relacionaron con el contagio por COVID-19, como la gravedad de la enfermedad y el riesgo de muerte. Además, se observó una mayor prevalencia de trastornos mentales comunes, como la ansiedad y la depresión. Por lo tanto, la salud materna de las mujeres con hiperglucemia durante el embarazo se ha visto afectada negativamente durante la pandemia de la COVID-19 en Brasil.

Diabetes materna y deficiencia de zinc: riesgos para la descendencia / Maternal diabetes and zinc deficiency, risks for the offspring

Resumen ANTECEDENTES: Cuando la mujer embarazada tiene déficit de zinc, esta carencia puede ser un factor que contribuya a la aparición de alteraciones en el feto, como las malformaciones congénitas y otros trastornos del desarrollo. OBJETIVO: Identificar los aspectos relevantes del estado actual del conocimiento de las complicaciones de la diabetes en la mujer embarazada y el déficit de zinc en el feto. Además, explicar cuál es la posible consecuencia de la deficiencia del micronutriente, entre otras causas moleculares subyacentes. METODOLOGÍA: Revisión bibliográfica efectuada en las bases de datos de Google, PubMed-Medline y SciELO de artículos publicados en inglés o español del año 2012 al 2022, con los MeSH: Maternal diabetes; Hyperglycemia; Zinc deficiency; Congenital malformations; Epigenetics; con su correspondiente traducción al español. Criterios de selección: artículos originales, estudios prospectivos, de revisión bibliográfica, metanálisis, capítulos de libro y reportes de la Asociación Americana de Diabetes (ADA) y la Asociación Latinoamericana de Diabetes (ALAD). RESULTADOS: Se localizaron 187 artículos de los que se excluyeron 126 no adecuados para el tema de la revisión, duplicados o en idioma diferente al inglés y español. CONCLUSIONES: El análisis bibliográfico evidenció que los trastornos metabólicos provocados por la hiperglucemia de la madre, el déficit de zinc, la alteración de su homeostasis y su interacción con el desequilibrio redox, la inflamación de bajo grado, la activación apoptósica y las modificaciones epigenéticas producen un ambiente intrauterino adverso que condiciona la aparición de malformaciones y otros trastornos del desarrollo en la descendencia.

Abstract BACKGROUND: When pregnant women are deficient in zinc, this deficiency may be a contributing factor to foetal disorders, such as congenital malformations and other developmental disorders. OBJECTIVE: To identify the relevant aspects of the current state of knowledge of the complications of diabetes in pregnant women and zinc deficiency in the foetus. In addition, to explain the possible consequences of micronutrient deficiency, among other underlying molecular causes. METHODOLOGY: Bibliographic review carried out in Google, PubMed-Medline and SciELO databases of articles published in English or Spanish from 2012 to 2022, with the MeSH: Maternal diabetes; Hyperglycemia; Zinc deficiency; Congenital malformations; Epigenetics; with their corresponding translation into Spanish. Selection criteria: original articles, prospective studies, literature reviews, meta-analyses, book chapters and reports of the American Diabetes Association (ADA) and the Latin American Diabetes Association (ALAD). RESULTS: 187 articles were located of which 126 unsuitable for the review topic, duplicates or in language other than English and Spanish were excluded. CONCLUSIONS: The literature review evidenced that metabolic disorders caused by maternal hyperglycemia, zinc deficiency, alteration of its homeostasis and its interaction with redox imbalance, low-grade inflammation, apoptotic activation and epigenetic modifications produce an adverse intrauterine environment that conditions the appearance of malformations and other developmental disorders in the offspring.

Maternal-fetal outcomes of pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections during pregnancy - A Brazilian health care referral center cohort study

ABSTRACT Objective: Pregnant women with type 1 diabetes (T1D) have an increased risk of maternal-fetal complications. Regarding treatment, continuous subcutaneous insulin infusion (CSII) has advantages compared to multiple daily injections (MDI), but data about the best option during pregnancy are limited. This study's aim was to compare maternal-fetal outcomes among T1D patients treated with CSII or MDI during pregnancy. Subjects and methods: This study evaluated 174 pregnancies of T1D patients. Variables of interest were compared between the groups (CSII versus MDI), and logistic regression analysis was performed (p < 0.05). Results: Of the 174 included pregnancies, CSII was used in 21.3% (37) and MDI were used in 78.7% (137). HbA1c values improved throughout gestation in both groups, with no difference in the first and third trimesters. The frequency of cesarean section was significantly higher in the CSII group [94.1 vs. 75.4%, p = 0.017], but there was no significant difference in the frequency of other complications, such as miscarriage, premature delivery and preeclampsia. The mean birth weight and occurrence of neonatal complications were also similar, except for the proportion of congenital malformations, which was significantly lower in the CSII group [2.9 vs. 15.6%, p = 0.048]. In regression analysis, the association of CSII with cesarean section and malformations lost significance after adjusting for HbA1c and other covariates of interest. Conclusion: In this study, we observed a higher frequency of cesarean section and a lower occurrence of congenital malformations in the CSII group, but the adjusted results might indicate that these associations are influenced by glycemic control.

Monitoreo continuo de glucosa durante la gestación en pacientes con diabetes mellitus tipo 2 pregestacional

La diabetes pregestacional requiere un control glicémico estricto durante el embarazo. Los dispositivos de monitoreo continuo de glucosa (MCG) miden niveles de glucosa intersticial sin necesidad de punción capilar. Se estudió 4 gestantes con diabetes mellitus tipo 2 pregestacional con la ayuda del MCG durante 2 semanas de su gestación. Ellas tuvieron sesiones nutricionales semanales y controles médicos con un endocrinólogo. El promedio de nivel de glucosa osciló entre 82 y 171 mg/dL. El MCG permitió cambios tempranos en el tratamiento de una paciente con hipoglicemia. Todas las pacientes manifestaron que el MCG les ayudó en la selección de sus alimentos. En conclusión, el MCG ayudó en el reconocimiento de carbohidratos y en el reajuste del tratamiento. El MCG tuvo buena aceptación de su uso.

Pregestational diabetes requires strict glycemic control during pregnancy. Continuous glucose monitoring (CGM) devices measure interstitial glucose levels without the need for capillary puncture. Four pregnant women with pregestational type 2 diabetes mellitus were studied with the aid of CGM during 2 weeks of their gestation. They had weekly nutritional sessions and medical controls with an endocrinologist. The average glucose level ranged from 82 to 171 mg/dL. The CGM allowed early changes in the treatment of one patient with hypoglycemia. All patients stated that the GCM helped them in their food selection. In conclusion, the GCM helped in carbohydrate recognition and treatment readjustment. The CGM was well accepted for use.

Hyperglycemia in pregnancy: sleep alterations, comorbidities and pharmacotherapy

SUMMARY OBJECTIVE: To investigate sleep alterations and associated factors in pregnant diabetic women (n=141). METHODS: Sleep profile, sociodemographics and clinical information were collected. Poor sleep quality (Pittsburgh Sleep Quality Index >5) and excessive daytime sleepiness (Epworth Sleepiness Scale ≥10), sleep duration (h), sleep latency (min), frequent sleep interruption and short sleep (≤6 h) were assessed in type 1 diabetes mellitus (16.3%), type 2 diabetes mellitus (25.5%) and gestational diabetes mellitus (58.2%). RESULTS: Poor sleep quality was found in 58.8% of patients and daytime sleepiness in 25.7%, regardless of hyperglycemia etiology. No correlation existed between daytime sleepiness and poor sleep quality (Pearson correlation r=0.02, p=0.84). Short sleep duration occurred in 1/3 of patients (31.2%). Sleep interruptions due to frequent urination affected 72% of all and sleep interruptions due to any cause 71.2%. Metformin was used by 65.7% of type 2 diabetes mellitus and 28.7% of gestational diabetes mellitus. In gestational diabetes mellitus, parity number was independently associated with poor sleep quality (p=0.02; OR=1.90; 95%CI 1.07-3.36) and metformin use was also independently associated with poor sleep quality (p=0.03; OR=2.36; 95%CI 1.05-5.29). CONCLUSIONS: Our study originally shows that poor sleep quality and excessive daytime sleepiness are frequent in diabetic pregnancy due to different etiologies. Interestingly, only in gestational diabetes mellitus, metformin therapy and higher parity were associated with poor sleep quality.

Serum from pregnant women with gestational diabetes mellitus increases the expression of FABP4 mRNA in primary subcutaneous human pre-adipocytes

OBJECTIVE: Gestational diabetes mellitus (GDM) is defined as glucose intolerance first detected during pregnancy. It can result in pregnancy complications such as birth injury, stillbirth. Fatty acid-binding protein 4 (FABP4), found in adipose tissue, is associated with insulin resistance, and type 2 diabetes. The aim of this study was to investigate whether FABP4 in the placenta and decidua of pregnant women with GDM is higher than that in normal pregnant women, and whether serum from pregnant women with GDM may cause adipocytes to secrete more FABP4 than does serum from a normal pregnant group. METHODS: We obtained placentas, deciduas, and serum from 12 pregnant women with GDM and 12 normal pregnant women and performed enzyme-linked immunosorbent assay, real time quantitative-polymerase chain reaction. We cultured human pre-adipocytes for 17 days with GDM and non-GDM serum and performed western blot, real time quantitative-polymerase chain reaction, and oil red O staining. RESULTS: Expression of FABP4 in serum, placenta and decidua of pregnant women with GDM was significantly higher than that in normal pregnant women. Serum from pregnant women with GDM increased the expression of FABP4 mRNA and decreased the expression of adiponectin mRNA in human pre-adipocytes significantly. Adipocyte cultured in GDM serum showed significantly greater lipid accumulation than those cultured in normal serum. CONCLUSION: Our results suggest that FABP4 is higher in placenta and decidua from pregnant women with GDM. Increased circulating FABP4 in maternal serum from pregnant women with GDM may originate from adipocytes and the placenta. Circulating FABP4 can induce increased insulin resistance and decreased insulin sensitivity.

Characteristics of pre-gestational diabetes mellitus diagnosed during pregnancy and the effects on pregnancy outcomes / 中华妇产科杂志

Objective To analyze the characteristics of pre-gestational diabetes mellitus (PGDM) diagnosed during pregnancy (missed diagnosis before pregnancy), and to evaluate the effects of diagnostic time on pregnancy outcomes. Methods A retrospective study of 746 pregnant women who were diagnosed PGDM and delivered in Peking University First Hospital from January 1st, 2005 to December 31st, 2015 was conducted. The patients were divided into 2 group. Those diagnosed PGDM before pregnancy were defined as Group diagnosed before pregnancy, and those diagnosed during pregnancy were defined as Group diagnosed during pregnancy. In Group diagnosed during pregnancy, those diagnosed before 24 gestational weeks were defined as Group diagnosed during pregnancy A, and those diagnosed after 24 weeks were defined as Group diagnosed during pregnancy B. The prevalence of adverse pregnancy outcomes in each group were analyzed. Results (1) Rate of missed diagnosis for PGDM:the incidence of PGDM diagnosed before pregnancy was 32.2% (240/746), and those diagnosed during pregnancy (missed diagnosis before pregnancy) was 67.8% (506/746). (2) Blood glucose control during pregnancy: ①Group diagnosed before pregnancy and Group diagnosed during pregnancy: the highest glycosylated hemoglobin (HbA1c) in Group diagnosed before pregnancy was (6.6±1.1)%, higher than that in Group diagnosed during pregnancy [(6.3± 1.0)%, P=0.019]. However, there was no significant difference in the average HbA1c level between the 2 groups (P=0.616). The insulin needed percentage [90.8%(218/240) vs. 53.8%(272/506)] in Group diagnosed before pregnancy were higher than that in Group diagnosed during pregnancy (P<0.01).②Group diagnosed during pregnancy A and B:the highest HbA1c in Group diagnosed during pregnancy A was (6.9± 1.3)%, higher than that in Group diagnosed during pregnancy B [(6.1 ± 0.8)%, P<0.05]. And the average HbA1c in Group diagnosed during pregnancy A [(6.4±0.8)%] was also higher than that in Group diagnosed during pregnancy B [(6.0 ± 0.8)%, P<0.05]. In Group diagnosed during pregnancy B, 46.1%(187/406) used insulin, lower than the percentage in Group diagnosed during pregnancy A (85.0%, 85/100;P<0.01). ③There were no significant differences in the highest HbA1c and the average HbA1c between Group diagnosed during pregnancy A and Group diagnosed before pregnancy (P=0.020, P=0.037). There was neither no significant difference in the percentage used insulin during pregnancy between them (P=0.128). There were significant differences in the highest HbA1c and the average HbA1c between Group diagnosed during pregnancy B and Group diagnosed before pregnancy (P<0.01, P=0.014). There was also significant difference in the percentage used insulin during pregnancy between them (P<0.01). (3) Pregnancy outcome:①Group diagnosed before pregnancy and Group diagnosed during pregnancy: the cesarean section rate [72.5% (174/240) vs. 59.7% (302/506)] in Group diagnosed before pregnancy were higher than those in Group diagnosed during pregnancy (P<0.01). However, there were no significant differences in preterm birth rate, pre-eclampsia, macrosomia percentage, percentage of neonates being hospitalized between the 2 groups (P=0.546,P=1.000,P=0.671,P=0.804). ②There was no significant difference in preterm birth rate, cesarean delivery rate, macrosomia percentage, pre-eclampsia rate, percentage of neonates being hospitalized between Group diagnosed during pregnancy A and Group diagnosed during pregnancy B (P=0.887, P=0.495, P=0.841, P=1.000, P=1.000).③There was no significant difference in preterm birth rate, cesarean delivery rate, macrosomia percentage, pre-eclampsia rate, percentage of neonates being hospitalized between Group diagnosed during pregnancy A and Group diagnosed before pregnancy (P=0.875, P=0.093, P=0.662, P=1.000, P=0.837). The cesarean delivery rate was lower in Group diagnosed during pregnancy B than that in Group diagnosed before pregnancy (P=0.001). However, there were no significant differences in preterm birth rate, macrosomia percentage, pre-eclampsia rate, percentage of neonates being hospitalized between them (P=0.530, P=0.776, P=1.000, P=0.797). Conclusions The diagnosis of PGDM is commonly missed before pregnancy. Fasting plasma glucose should be used as screening test to identify PGDM at pre-pregnancy examination or first antenatal care. Using abnormal value of 2-hour glucose after 24 gestational weeks as the only way to diagnose PGDM is not suitable.

Investigation of pregestational diabetes mellitus in 15 hospitals in Guangdong province / 中华妇产科杂志

Objective To investigate the morbidity, diagnostic profile and perinatal outcome of pregestational diabetes mellitus (PGDM) in 15 hospitals in Guangdong province. Methods A total of 41338 women delivered in the 15 hospitals during the 6 months,195 women with PGDM(PGDM group) and 195 women with normal glucose test result(control group)were recruited from these tertiary hospitals in Guangdong province from January 2016 to June 2016. The morbidity and diagnostic profile of PGDM were analyzed. The complications during pregnancy and perinatal outcomes were compared between the two groups. In the PGDM group, pregnancy outcomes were analyzed in women who used insulin treatment (n=91) and women who did not (n=104). Results (1)The incidence of PGDM was 0.472%(195/41338). Diabetes mellitus were diagnosed in 59 women (30.3%, 59/195) before pregnancy, and 136 women (69.7%,136/195) were diagnosed as PGDM after conceptions. Forty-six women (33.8%) were diagnosed by fasting glucose and glycohemoglobin (HbA1c) screening. (2) The maternal age, pre-pregnancy body mass index (BMI), prenatal BMI, percentage of family history of diabetes, incidence of macrosomia, concentration of low density lipoprotein were significantly higher in PGDM group than those in control group (all P<0.05). Women in PGDM group had significantly higher HbA1c concentration((6.3±1.3)% vs (5.2±0.4)%), fasting glucose [(6.3±2.3) vs (4.8±1.1) mmol/L], oral glucose tolerance test(OGTT)-1 h glucose((12.6±2.9) vs (7.1± 1.3) mmol/L)and OGTT-2 h glucose [(12.0±3.0) vs (6.4±1.0) mmol/L] than those in control group (P<0.01). (3)The morbidity of preterm births was significantly higher (11.3% vs 1.0%, P<0.01), and the gestational age at delivery in PGDM group was significantly smaller [(37.6±2.3) vs (39.2±1.2) weeks, P<0.01]. Cesarean delivery rate in the PGDM group (70.8% vs 29.7%) was significantly higher than the control group (P<0.01). There was significantly difference between PGDM group and control in the neonatal male/female ratio (98/97 vs 111/84, P=0.033). The neonatal birth weight in PGDM group was significantly higher((3159±700) vs (3451±423) g, P<0.01). And the incidence of neonatal hypoglycemia in the PGDM group was higher than the control group (7.7% vs 2.6%, P=0.036).(4)In the PGDM group, women who were treated with insulin had a smaller gestational age at delivery [(36.9±2.9) vs (37.9±2.5) weeks, P<0.01], and the neonates had a higher neonatal ICU(NICU)admission rate (24.2% vs 9.6% , P<0.01). Conclusions The morbidity of PGDM in the 15 hospitals in Guangdong province is 0.472%. The majority of PGDM was diagnosed during pregnancy; HbA1c and fasting glucose are reliable parameters for PGDM screening. Women with PGDM have obvious family history of diabetes and repeated pregnancy may accelerate the process of diabetes mellitus. Women with PGDM have higher risk for preterm delivery and neonatal hypoglycemia. Unsatisfied glucose control followed by insulin treatment may increase the need for NICU admission.

Uso do prontuário eletrônico na assistência pré-natal às portadoras de diabetes na gestação / Electronic Medical Record for Prenatal Care of Diabetic Women

Objetivo Apresentar e validar um registro eletrônico de saúde (RES) multifuncional para atendimento ambulatorial a portadoras de endocrinopatias na gestação e comparar a taxa de preenchimento de informações de saúde com o prontuário convencional. Métodos Desenvolvemos um RES denominado Ambulatório de Endocrinopatias na Gestação eletrônico (AMBEG) para registro sistematizado das informações de saúde. O AMBEG foi utilizado para atendimento obstétrico e endocrinológico de gestantes acompanhadas no ambulatório de endocrinopatias na gestação na maternidade referência em gestação de alto risco na Bahia, no período de janeiro de 2010 a dezembro de 2013. Aleatoriamente foramselecionadas 100 pacientes atendidas como AMBEG e 100 pacientes atendidas comprontuário convencional comregistro em papel e comparou-se a taxa de preenchimento de informações clínicas. Resultados Foram realizados 1461 atendimentos com o AMBEG: 253, 963 e 245 respectivamente, admissões, consultas de seguimento e puerpério. Eram portadoras de diabetes 77,2% e sendo 60,1% portadoras de diabetes pré-gestacional. O AMBEG substituiu, satisfatoriamente, o prontuário convencional. O percentual de informações clínicas registradas em ambos os prontuários foi significativamente maior no AMBEG: queixas clínicas (100 versus 87%, p < 0,01), altura uterina (89 versus 75%, p = 0,01), ganho de peso total (91 versus 40%, p < 0,01) e dados específicos sobre o diabetes (dieta, esquema de insulina, controle glicêmico e manejo de hipoglicemias) revelando diferença significativa (p < 0,01). A possibilidade de exportar dados clínicos para planilhas facilitou e agilizou a análise estatística de dados. Conclusões O AMBEG é uma ferramenta útil no atendimento clínico a mulheres portadoras de endocrinopatias na gestação. A taxa de preenchimento de informações clínicas foi superior à do prontuário convencional.

Objective To present and validate a multifunctional electronic medical record (EMR) for outpatient care to women with endocrine disorders in pregnancy and to compare health information data fill rate to conventional medical records. Methods We developed an EMR named Ambulatory of Endocrine Diseases in Pregnancy (AMBEG) for systematic registration of health information The AMBEG was used for obstetric and endocrine care in a sample of pregnant women admitted to the maternity reference in high-risk pregnancies in Bahia from January 2010 to December 2013. We randomly selected 100 patients accompanied with AMBEG and 100 patients monitored with conventional consultation and compared the health information data fill rate of the electronic consultation to that performed using conventional medical records. Results 1461 consultations were held, of which 253, 963 and 245 were first, follow-up and puerperium consultations, respectively. Most patients were pregnant women with diabetes (77.2%) and 60.1% were women with pre-gestational diabetes. The AMBEG satisfactorily replaced the conventional medical record. The percentage of registered information was significantly higher in the AMBEG: clinical symptoms (87% versus 100, p < 0.01), uterine height (89 versus 75%, p = 0.01), total weight gain (91 versus 40%, p < 0.01) and specific diabetes data (diet, insulin regimen, glycemic control and management of hypoglycemia) revealed a significant difference (p < 0.01). The ability to export data to worksheets greatly facilitated and accelerated the statistical analysis of the data. Conclusions AMBEG is a useful tool in clinical care for women with endocrine diseases during pregnancy. The fill rate of clinical information was superior to that registered in conventional medical records.

Diabetes in pregnancy

Nowadays in Korea, the number of pregnant women with diabetes mellitus is steadily growing due to increases in advanced maternal age and obesity in combination with changes in lifestyle and diet patterns. Pregnancy complicated with diabetes mellitus, whether it is gestational or pregestational, is associated with an increased number of maternal morbidities and adverse obstetric outcomes. Therefore, it is very important to screen, diagnose, manage, and prevent diabetes mellitus during, and even before, pregnancy. In order to improve maternal and perinatal outcomes of pregnancies complicated by diabetes mellitus, research is needed on the standardization of screening and the diagnostic criteria for gestational diabetes, appropriate surveillance techniques for diabetic mothers and fetuses, and the optimal timing of delivery. To facilitate compliance of women with diabetes, randomized studies on the long-term safety and effects of oral hypoglycemics are also needed.

Movimentos respiratórios fetais em gestações com diabetes mellitus pré-gestacional / Fetal breathing movements in pregnancies complicated by pregestational diabetes mellitus

OBJETIVO: analisar o padrão dos movimentos respiratórios fetais (MRF) em gestantes diabéticas no terceiro trimestre de gestação. MÉTODOS: foram avaliadas 16 gestantes com diabetes mellitus pré-gestacional e 16 gestantes normais (grupo controle), com os seguintes critérios de inclusão: gestação única entre a 36ª e a 40ª semana, ausência de outras doenças maternas e ausência de anomalias fetais. No perfil biofísico fetal (PBF), foram avaliados os parâmetros: freqüência cardíaca fetal, MRF, movimentos corpóreos fetais, tônus fetal e índice de líquido amniótico. Os MRF foram avaliados por 30 minutos, período em que o exame foi integralmente gravado em fita de vídeo VHS para posterior análise do número de episódios de MRF, do tempo de duração dos episódios e do índice de movimentos respiratórios fetais (IMR). O IMR foi calculado pela fórmula: (intervalo de tempo com MRF/tempo de observação) x 100. No início e no final do PBF foi dosada a glicemia capilar materna. Os resultados foram analisados pelo teste de Mann-Whitney U e teste exato de Fisher, adotando-se nível de significância de 5 por cento. RESULTADOS: as glicemias demonstraram média significativamente superior nas diabéticas (113,3±35,3 g/dL) em relação às gestantes normais (78,2±14,8 g/dL, p<0,001). A média do índice de líquido amniótico mostrou-se maior no grupo das gestantes diabéticas (15,5±6,4 cm) quando comparado aos controles (10,6±2,0 cm; p=0,01). A média do número de episódios de MRF foi superior nas diabéticas (22,6±4,4) em relação aos controles (14,8±2,3; p<0,0001). A média do IMR nas diabéticas (54,6±14,8 por cento) foi significativamente maior do que no grupo controle (30,5±7,4 por cento; p<0,0001). CONCLUSÕES: os maiores valores glicêmicos podem estar associados a diferente padrão nos movimentos respiratórios de fetos de mães diabéticas. A utilização deste parâmetro do PBF, na prática clínica, deve ser considerada...

PURPOSE: to analyze the pattern of fetal breathing movements (FBM) in diabetic pregnant women in the third trimester of pregnancy. METHODS: sixteen pregestational diabetic and 16 nondiabetic (control group) pregnant subjects were included fulfilling the following criteria: singleton, between 36-40 weeks of gestation, absence of other maternal diseases and absence of fetal anomalies. The fetal biophysical profile (FBP) was performed to evaluate the following parameters: fetal heart rate, FBM, fetal body movements, fetal tone and amniotic fluid index. The FBM was evaluated for 30 minutes, period when the examination was integrally recorded in VHS video for posterior analysis of the number of FBM episodes, the duration of each episode and the fetal breathing movements index (BMI). The BMI was calculated by the formula: (interval of time with FBM/total time of observation) x 100. At the beginning and in the end of the FBP maternal glucose levels were checked. The results were analyzed by the Mann-Whitney U-test and the Fisher exact test, adopting a level of significance of 5 percent. RESULTS: the glucose levels demonstrated significantly superior average in the diabetic group (113.3±35.3 g/dL) in relation to the normal group (78.2±14.8 g/dL, p<0.001). The average of the amniotic fluid index was higher in the group of the diabetic cases (15.5±6.4 cm) when compared with controls (10.6±2.0 cm; p=0.01). The average of the number of FBM episodes was superior in the diabetic ones (22.6±4.4) in relation to controls (14.8±2.3; p<0.0001). The average of the BMI in the diabetic patients (54.6±14.8 percent) was significantly higher than that in the control group (30.5±7.4 percent, p<0.0001). CONCLUSIONS: the elevated blood glucose levels can be associated with a different pattern in the FBM of diabetic mothers. The use of this parameter of the FBP, in the obstetric practice, must be considered...

O uso de adoçantes na gravidez: uma análise dos produtos disponíveis no Brasil / The use of sweeteners in pregnancy: an analysis of products available in Brazil

Os adoçantes são freqüentemente utilizados por mulheres em idade reprodutiva. Esta é uma revisão narrativa da literatura a respeito dos adoçantes atualmente comercializados no mercado brasileiro. Existem poucas informações sobre o uso da sacarina e ciclamato na gestação, e seus efeitos sobre o feto. Devido às limitadas informações disponíveis e ao seu potencial carcinogênico em animais, a sacarina e o ciclamato devem ser evitados durante a gestação (risco C). O aspartame tem sido extensivamente estudado em animais, sendo considerado seguro para uso na gestação (risco B), exceto para mulheres homozigóticas para fenilcetonúria (risco C). A sucralose e o acessulfame-K não são tóxicos, carcinogênico ou mutagênicos em animais, mas não existem estudos controlados em humanos. Porém, como esses dois adoçantes não são metabolizados, parece improvável que seu uso durante a gestação possa ser prejudicial (risco B). A estévia, substância derivada de uma planta nativa brasileira, não produz efeitos adversos sobre a gestação em animais, porém não existem estudos em humanos (risco B). Os agentes de corpo usados na formulação dos adoçantes (manitol, sorbitol, xilitol, eritrol, lactilol, isomalte, maltilol, lactose, frutose, maltodextrina, dextrina e açúcar invertido) são substâncias consideradas seguras para o consumo humano. Concluindo, segundo as evidências atualmente disponíveis, o aspartame, a sucralose, o acessulfame e a estévia podem ser utilizados com segurança durante a gestação.

Sweeteners are frequently used by women of reproductive age. This is a narrative review about the sweeteners currently sold in the Brazilian commerce. There is a few information on the use of saccharin and cyclamates in pregnancy and their effects on the fetus. Due to the limited information available and their carcinogenic potential in animal species, saccharin and cyclamates should be avoided during pregnancy (risk C). Aspartame has been extensively studied in animals and it is considered safe for use during pregnancy (risk B), except by women homozygous for phenylketonuria (risk C). Sucralose and acessulfame-K are not toxic, carcinogenic or mutagenic in animals, but there are no controlled studies in humans. However, since these two sweeteners are not metabolized, it is unlikely that their use during pregnancy could be harmful (risk B). Stevia, a substance extracted from a native Brazilian plant, is innocuous in animal pregnancies, but there are no controlled studies in humans (risk B). Body agents found in the composition of artificial sweeteners (mannitol, sorbitol, xylitol, erithrol, lactilol, isomalt, maltilol, lactose, fructose, maltodextrin, dextrin, and inverted sugar) are substances generally regarded as safe for human consumption. In conclusion, according to the currently available evidence, aspartame, sucralose, acessulfame-K and stevia can be safely used during pregnancy.