A Brazilian cohort of pregnant women with overt diabetes: analyses of risk factors using a machine learning technique

ABSTRACT Objective: Pregnancy complicated by type 2 diabetes is rising, while data on type 2 diabetes first diagnosed in pregnancy (overt diabetes) are scarce. We aimed to describe the frequency and characteristics of pregnant women with overt diabetes, compare them to those with known pregestational diabetes, and evaluate the potential predictors for the diagnosis of overt diabetes. Subjects and methods: A retrospective cohort study including all pregnant women with type 2 diabetes evaluated in two public hospitals in Porto Alegre, Brazil, from May 20, 2005, to June 30, 2021. Classic and obstetric factors associated with type 2 diabetes risk were compared between the two groups, using machine learning techniques and multivariable analysis with Poisson regression. Results: Overt diabetes occurred in 33% (95% confidence interval: 29%-37%) of 646 women. Characteristics of women with known or unknown type 2 diabetes were similar; excessive weight was the most common risk factor, affecting ~90% of women. Age >30 years and positive family history of diabetes were inversely related to a diagnosis of overt diabetes, while previous delivery of a macrosomic baby behaved as a risk factor in younger multiparous women; previous gestational diabetes and chronic hypertension were not relevant risk factors. Conclusion: Characteristics of women with overt diabetes are similar to those of women with pregestational diabetes. Classic risk factors for diabetes not included in current questionnaires can help identify women at risk of type 2 diabetes before they become pregnant.

Pregestational Diabetes and Congenital Heart Defects / Diabetes pré-gestacional e defeitos cardíacos congênitos

Abstract Studies have consistently shown a significant increase in the risk of congenital heart defects in the offspring of diabetic mothers compared with those of nondiabetic pregnancies. Evidence points that all types of pregestational diabetes have the capacity of generating cardiac malformations in a more accentuated manner than in gestational diabetes, and there seems to be an increased risk for all congenital heart defects phenotypes in the presence of maternal diabetes. Currently, the application of some therapies is under study in an attempt to reduce the risks inherent to diabetic pregnancies; however, it has not yet been possible to fully prove their effectiveness. The present review aims to better understand the mechanisms that govern the association between pregestational diabetes and congenital heart defects and how maternal diabetes interferes with fetal cardiac development, as there is still a long way to go in the investigation of this complex process.

Resumo Estudos têm demonstrado consistentemente um aumento significativo no risco de defeitos cardíacos congênitos em filhos de mães diabéticas em comparação com os de gestações não diabéticas. Evidências apontam que todos os tipos de diabetes pré-gestacional têm capacidade de gerar malformações cardíacas mais acentuadas do que no diabetes gestacional e parece haver um risco aumentado para todos os fenótipos de cardiopatias congênitas na presença de diabetes materno. Atualmente, está em estudo a aplicação de algumas terapias na tentativa de diminuir os riscos inerentes à gravidez diabética; no entanto, ainda não foi possível comprovar totalmente a sua eficácia. A presente revisão visa compreender melhor os mecanismos que regem a associação entre diabetes pré-gestacional e cardiopatias congênitas e como o diabetes materno interfere no desenvolvimento cardíaco fetal, pois ainda há um longo caminho a percorrer na investigação deste processo complexo.

Retinopatía diabética y diabetes mellitus pregestacional: una mirada integral desde la oftalmología / Diabetic Retinopathy and Pregestational Diabetes Mellitus: a Comprehensive View from Ophthalmology

El incremento de la prevalencia de diabetes mellitus a nivel global en los últimos años la convierte en un desafío para los sistemas de salud. La retinopatía diabética como una de sus complicaciones crónicas más frecuentes se convierte en una de las principales causas de ceguera prevenible en el mundo, convirtiéndose el embarazo en un factor de riesgo importante para el desarrollo de esta enfermedad. El embarazo en mujeres con diagnóstico previo de diabetes mellitus, puede favorecer la aparición y la progresión de la retinopatía diabética. En esta etapa, las alteraciones metabólicas descritas de la diabetes mellitus se unen a las propias del embarazo con lo que el cuadro clínico se refuerza y acentúa, de hecho, se considera el mayor factor de riesgo y se asocia con un incremento en su prevalencia y gravedad. La presencia de retinopatía diabética no es una contraindicación para el embarazo, pero su diagnóstico y tratamiento precoz para prevenir la pérdida de visión, es esencial para preservar la calidad de vida de las gestantes previa y posterior al parto. La aparición y progresión de la retinopatía diabética en mujeres con diabetes mellitus pregestacional, se puede prevenir o reducir con una adecuada atención preconcepcional, un riguroso seguimiento clínico durante el embarazo y un temprano tratamiento, contribuyendo así a evitar la pérdida visual por esta causa(AU)

The increase in the prevalence of diabetes mellitus globally in recent years makes it a challenge for health systems. Diabetic retinopathy as one of its most frequent chronic complications has become one of the main causes of preventable blindness in the world, and pregnancy has become an important risk factor for the development of this disease. Pregnancy in women previously diagnosed with diabetes mellitus may favor the onset and progression of diabetic retinopathy. At this stage, the metabolic alterations described for diabetes mellitus are added to those of pregnancy itself, so that the clinical picture is reinforced and accentuated, in fact, it is considered the greatest risk factor and is associated with an increase in its prevalence and severity. The presence of diabetic retinopathy is not a contraindication for pregnancy, but its early diagnosis and treatment to prevent vision loss is essential to preserve the quality of life of pregnant women before and after delivery. The onset and progression of diabetic retinopathy in women with pregestational diabetes mellitus can be prevented or reduced with adequate preconception care, rigorous clinical follow-up during pregnancy and early treatment, thus helping to prevent visual loss due to this cause(AU)

The situation and feature of the intensive insulin therapy in a group of hyperglycemic patients during pregnancy / 中华内分泌代谢杂志

Relevant clinical data of 141 cases diagnosed pregestational diabetes mellitus(PGDM),diabetes mellitus in pregnancy(DIP), gestational diabetes mellitus(GDM), and type 2 diabetes mellitus(T2DM) were collected. The blood glucose control rate,insulin dose,and episode of hypoglycemia in the insulin intensive therapy were retrospectively analyzed. The results showed that there was no significant difference in the control rate among the four groups(P=0.906). The insulin dose/weight in GDM was significantly lower than those in PGDM,DIP,and T2DM groups[0.65(0.47-1.00),0.67(0.38-1.05),0.65(0.52-0.82)vs 0.45(0.29-0.61)U·kg-1·d-1,P<0.05 or P<0.01]. There was no significant difference in episode or incidence rate of hypoglycemia among the overall four groups(P=0.339). However in the patients with blood glucose reaching the control standard,the rate of hypoglycemia in T2DM was significantly higher than those in PGDM,DIP,and GDM(P<0.05 or P<0.01).

Diabetes y Embarazo: Acuerdos y Controversias sobre el diagnóstico y tratamiento / Diabetes and Pregnancy: Agreements and controversies on diagnosis and treatment

El manejo adecuado de la diabetes durante el embarazo es fundamental para prevenir morbi-mortalidad materna y perinatal. No hay consenso en las pautas internacionales, existiendo muchos aspectos controversiales. Se realizó una revisión del tema buscando criterios científicos y costo-efectivos que sirvan de base para prestar la mejor atención a las pacientes con Diabetes y Embarazo. Hay acuerdo general sobre la necesidad de equipos interdisciplinarios que proporcionen seguimiento clínico-metabólico materno, donde el control glucémico óptimo alcanzado y mantenido durante toda la gestación constituye la piedra angular, para lo cual resulta indispensable la indicación y cumplimiento de medidas no farmacológicas como educación, plan alimentario, ejercicios, cesación tabáquica y apoyo psico-social; y medidas farmacológicas, donde la insulina constituye el tratamiento de elección. Además de realizar la vigilancia de la salud fetal, la atención obstétrica de un embarazo de alto riesgo y los cuidados inmediatos del recién nacido. Desafortunadamente, persisten numerosas controversias particularmente en cuanto a la pesquisa de las hiperglucemias en el embarazo (Diabetes Gestacional y Diabetes en el Embarazo) y las medidas terapéuticas y de control metabólico a aplicar. En el momento de seleccionar las opciones disponibles, se destaca la importancia del razonamiento clínico individualizado, el cumplimiento de las regulaciones y el abordaje ético, con el fin de garantizar la mayor seguridad al binomio madre-feto.

An adequate management of diabetes during pregnancy is fundamental to prevent related maternal and perinatal morbidity and mortality. There is no consensus on existing international guidelines, and many controversial aspects persist. A review of the subject was conducted, searching for scientific and costeffective criteria as the basis to provide the best care to patients with diabetes and pregnancy. There is a general agreement on the need for interdisciplinary teams that provide maternal clinicalmetabolic monitoring, where optimal glycemic control, achieved and maintained throughout pregnancy, is the cornerstone. For this, the indication and compliance of non-pharmacological measures, such as education, diet planning, exercise, smoking cessation and psychosocial support are essential, in addition to pharmacological measures, where insulin is the treatment of choice. Also, surveillance of fetal health, obstetric care in high risk pregnancies and immediate care of the newborn are needed. Unfortunately, many controversies still persist, particularly in terms of screening for hyperglycemia in pregnancy (Gestational Diabetes and Diabetes in pregnancy), as well as regarding applicable therapeutic and metabolic control measures. When selecting available options, the importance of an individualized clinical reasoning, compliance with regulations and ethical issues are emphasized in order to ensure greater safety to the mother-fetus binomial.

Discrepancy between Non-stress Test Result and Umbilical Artery Doppler Study in a Pregnancy Complicated by Diabetes; A Case Report / 대한주산의학회잡지

Pregestational diabetes is a well-known risk factor for perinatal mortality, and regarded as an important cause of stillbirth. Unfortunately, more than half of stillbirths remain unexplained. Nevertheless, there is no consensus regarding the optimal timing and content of antepartum testing in pregnancies complicated by diabetes. A 32-year-old primigravida presented with diabetes diagnosed during pregnancy. Antenatal fetal surveillance tests including nonstress test, biophysical profile, and Doppler waveforms of umbilical arteries were performed twice weekly, beginning at 32 weeks gestation. At 37(+4) weeks' gestation, a discrepancy in the surveillance test results arose when reversed end-diastolic flow in the umbilical arteries was seen, despite a reactive nonstress test. A male baby was delivered by cesarean section. The umbilical arterial pH at delivery was 7.171. Antenatal fetal surveillance in pregnancies complicated by diabetes should include evaluation of Doppler waveforms in the umbilical vessels, regardless of the presence or absence of maternal vasculopathy.

Atención hospitalaria en la vigilancia obstétrica y metabólica de la gestante diabética, una experiencia de trabajo / Hospital attention in obstetric and metabolic surveillance in diabetic pregnant women; a work experience

Introducción: se conoce que en los últimos años, el manejo obstétrico ha enfatizado el control estricto de la glicemia en la madre y que ha mejorado la sobrevida fetal, la cual es directamente proporcional a la glicemia media materna. Objetivo: caracterizar los principales resultados en la experiencia hospitalaria sobre la vigilancia obstétrica y metabólica en la atención de gestantes diabéticas en el Hospital General Ciro Redondo García, Centro de Referencia Territorial en Artemisa. Métodos: se realizó un estudio observacional analítico, prospectivo y de corte longitudinal en el Hospital General Docente Ciro Redondo García de Artemisa desde junio de 2005 hasta junio de 2012. De un universo de 2 140 gestantes ingresadas, 240 fueron diagnosticadas diabéticas, constituyendo la muestra de estudio, Resultados: como diabéticas gestacionales (DG) se clasificó el 77,5 por ciento mientras que las diabéticas pregestacionales (DPG) constituyeron el 22,5 por ciento .Los grupos de edades de 31 a 36 años y de 20 a 25 años fueron los de mayor predominio en la diabetes gestacional pregestacional para un 29,1 por ciento y un 33,3 por ciento respectivamente. Los factores de riesgo de mayor predominio en el estudio fueron: la obesidad (44,2 por ciento ), la edad mayor de 34 años, polihidramnios, macrosomía previa y los abortos espontáneos (38,7; 18; 8,1; y 6,6 por ciento respectivamente). Otros factores de riesgo fueron los antecedentes familiares de diabetes mellitus de las gestantes, el diagnóstico de la diabetes gestacional después de las 20 semanas, la cesárea como el tipo de parto de mayor predominio y la edad gestacional a término al parto. Conclusiones: en un valorado sistema de salud pública como el cubano, se debe tomar medidas pertinentes para monitorear y controlar la morbilidad y complicaciones de las gestantes diabéticas

Background: it is known that, in recent years, obstetric management has made emphasis on the strict control of glycemia in the mother and the fetal survival has been improved, which is directly proportional to the mean maternal glycemia. Objective: to characterize the principal results in the hospital experience on obstetric and metabolic surveillance in the management of pregnant diabetic women in Ciro Redondo García General Hospital, Regional Reference Center in Artemisa. Methods: an observational analytical prospective cross-longitudinal study was conducted in Ciro Redondo García General Hospital in Artemisa from June 2005 to June 2012. From a universe of 2 140 pregnant women admitted in the hospital, 240 were diagnosed diabetics, representing them, the sample of the study. Results: the 77.5 percent of them were classified as gestational diabetic women (GD) whereas pregestational diabetic women (PGD) represented the 22.5 percent .The 31-36 and 20-25 age groups were the most predominant in gestational and pregestational diabetes, for a 29.1 percent and a 33.3 percent, respectively. The most predominant risk factors in the study were: obesity (44.2 percent ), age over 34 years, polyhydramnios, previous macrosomia, and spontaneous abortion (38.7, 18, 8.1, 6.6 percent respectively). Other risk factors were: family antecedents of diabetes mellitus in pregnant women, the time of diagnosis of gestational diabetes after the 20 weeks, the caesarean section as the most predominant type of delivery, and gestational age at delivery at term. Conclusions: in a valued Public Health System such as the Cuban one, appropriate measures should be taken to monitor and control morbidity and complications in pregnant diabetic women

Marcadores de estrés oxidativo en embarazadas diabéticas / Markers of oxidative stress in diabetic pregnants

Introducción: El manejo del estrés oxidativo en la embarazada diabética podría ser beneficioso en la prevención de complicaciones como las malformaciones congénitas. Sin embargo, no existe un consenso en cuanto a la pertinencia de aplicar terapias antioxidantes previamente o durante la gestación. La ambigüedad de algunos resultados en cuanto al daño real sobre las biomoléculas pudiera ser la causa de tal desacuerdo. El estudio tuvo como objetivos evaluar el estado de marcadores de daño oxidativo a biomoléculas y de defensa antioxidante en embarazadas diabéticas, así como analizar la influencia del tipo diabetes en el estado REDOX durante la gestación. Métodos: Se estudiaron 32 embarazadas diabéticas (15 con diabetes pregestacional y 17 gestacional) y 27 sanas, con un tiempo de gestación promedio superior a 20 semanas. Los marcadores se evaluaron por técnicas espectrofotométricas y cromatografía líquida de alta presión. Resultados: se pudo asegurar daño oxidativo al material genético y a proteínas, unido a una disminución también significativa de las defensas antioxidantes mediadas por el glutatión reducido en las embarazadas con diabetes pregestacional. Los niveles de nitratos y nitritos no mostraron diferencias entre los grupos. Conclusiones: los resultados permiten asegurar una vez más que las mujeres con diabetes pregestacional presentan un estado de estrés oxidativo que deteriora las defensas antioxidantes y no logra contrarrestar el daño oxidativo a biomoléculas

Introduction: The management of oxidative stress in diabetic pregnants could be beneficial to prevent complications like the congenital malformations. However, there is not a consensus as regards the relevance of applying antioxidant therapies before or during pregnancy. The ambiguity of some results as regard the real damage on biomolecules could be the cause of such disagreement. The aims of present study were to assess the state of the markers of oxidative damage to biomolecules and the antioxidant defence in diabetic pregnants, as well as to analyze the influence of the type of diabetes on the REDOX state during pregnancy. Methods: Thirty two diabetic pregnants (15 with pregestational diabetes and 17 with gestational diabetes) and 27 healthy pregnants with an average pregnant time higher than 20 weeks. Markers were assessed using spectrophotometry and high-performance liquid chromatography techniques. Results: There was oxidative damage to genetic material and proteins together with a decrease also significant in antioxidant defenses mediated by the reduced glutathione in pregestational diabetic pregnants. The nitrates and nitrites levels were not different among groups. Conclusions: Results allowed us to make sure that women with pregestional diabetes had a oxidative stress state deteriorating the antioxidant defenses and not counteract the oxidative damage to biomolecules

Progress of pregestational diabetes mellitus and congenital heart defects / 国际儿科学杂志

Pregestational diabetes mellitus may cause fetal heart defects,and it is considered to be an important non-genetic risk factors for congenital heart defects. However, the pathogenesis is unclear. Recent studies have shown that hyperglycemia, which acts as a primary teratogen in pregestational diabetes mellitus, may affect the endocardial cushion formation and neural crest cell development. Cardiac oxidative stress damage, increased myocardial cell apoptosis,increased synthesis of extracellular matrix, as well as the alteration of heart development-related genes expression are important pathogenic mechanism. In this paper, we review the progress in the effect and the pathogenesis of pregestational diabetes mellitus on heart development.

Modificación del control glicémico en diabéticos tipo 1 y 2 durante el embarazo / Modification of glycemic control in diabetics type 1 and 2 during pregnancy

Introducción: Se ha demostrado que el control glicémico adecuado de la diabetes, tanto gestacional como pregestacional, especialmente en cuanto al aspecto educativo y de seguimiento, reduce de forma considerable la morbilidad perinatal y puede también mejorar la calidad de vida de la madre en el futuro. Es por ello, que este trabajo tiene como objetivo caracterizar a la población de diabéticas pregestacionales (diabéticas tipo 1 y 2), en cuanto a su grado de control glicémico evidenciado por el valor de la hemoglobina glicosilada (HbA1c), durante el embarazo y comparar este grado de control con pacientes diabéticas no embarazadas. Materiales y Método: Se realizó un estudio descriptivo retrospectivo de tipo cohorte histórica que incluyó como cohorte expuesta a las pacientes diabéticas tipo 1 como 2, atendidas en el Consultorio de Especialidades del Hospital Dr. Gustavo Fricke (HGF) entre Enero de 1999 y Junio de 2008. Como cohorte no expuesta, se seleccionaron pacientes diabéticas en edad fértil, no embarazadas en control en el Policlínico de Endocrinología del HGF y en Consultorio Marcos Maldonado, con características epidemiológicas equivalentes a las de las pacientes pertenecientes a la cohorte expuesta mediante técnica de matching. Resultados: Durante el embarazo, un 73,68 por ciento de los casos obtuvieron HbA1c bajo 7 mg/dL mientras que en el grupo de mujeres no embarazadas sólo un 15,62 por ciento HbA1c bajo 7mg/dL (p value=0.0000062). Conclusión: Durante el embarazo las pacientes diabéticas lograron un mejor control glicémico que las diabéticas no embarazadas. Sin embargo, no podemos afirmar que este mejor control se deba a la motivación del embarazo, o a un control preconcepcional adecuado con la información de la que disponemos. Probablemente la vigilancia más estrecha y frecuente por parte del equipo de salud sea un factor relevante.

It has been demostrated that a good glycemic control, in diabetic women, before anf during pregnancy, specially concerning education and follow up, may in better quality of life in the mother's future. This revision has the intention to characterize the population of pregestational diabetic women (type 1 and type 2), observing their glycosilated hemoglobine (Hb A1c) and compare it with similar diabetic non pregnant women. A retrospective descriptive review has been done, comparing an exposed cohort of type 1 and type 2 pregnant women controlled at the Endocrine Departament of Hospital Dr. G. Fricke in Viña del Mar, between January 1999 and June 2008, with a not exposed cohort of fertile non pregnant diabetic women, with equivalent epidemiologic characteristics for matching. As results we saw that during pregnancy 73, 68 percent had HbA1c less than 7mg/dL versus 15.62 percent in the control group. (p value=0.0000062) As a conclusion, we can say that during pregnancy diabetic women improve their glycemic control compared with similar non pregnant diabetic women. Nevertheless, we are not able to affirm that this improved metabolic control is a consequence of the motivation induced by pregnancy or because of better pregestational control. More likely, the tighter vigilance of the health team, with a greater frequency of medical visits has a lot to do with our findings.

Control preconcepcional de la paciente diabética / Pregestational control of the diabetic patient

Se realizó una amplia revisión de los cuidados que debe recibir una mujer diabética antes de que decida embarazarse. Es necesario lograr un control metabólico adecuado previo a la gestación para evitar la aparición de malformaciones fetales, que pueden presentarse si existe hiperglicemia durante el período de embriogénesis del embarazo. También es importante precisar la existencia de complicaciones crónicas de la diabetes mellitus y su grado, dado que algunas deben ser corregidas antes del embarazo, o en dependencia de la severidad o del tipo, pudieran desaconsejarlo. Se hace imprescindible además, brindar orientación anticonceptiva a estas mujeres mientras esperan el momento más adecuado para enfrentar la gestación. En este trabajo se recogen las experiencias en relación con este tema y las pautas de acción en la consulta de Riesgo Materno Preconcepcional de la Mujer Diabética.

An extensive literature review of the care that should be given to a diabetic woman before pregnancy was made. It is necessary to have an adequate metabolic control prior to gestation in order to avoid fetal malformation that may occur if hyperglycemia is present in the pregnancy embriogenesis term. It is similarly important to determine chronic complications of diatebes mellitus and their level of impact, given that some of these problems must be solved before pregnancy and, according to severity and type of the complication, a woman may even be advised against pregnancy. It is also essential to provide these women with contraceptive guidance while they are waiting for the most suitable time to get pregnant. This paper reflected the experience gained and the actions taken in the Pregestational Maternal Risk of the Diabetic Women medical consultation service.

Clinical Study of Maternal and Perinatal Complication in Pregnancy with Diabetes Mellitus / 대한산부인과학회잡지

OBJECTIVES: The aim of the current paper is to analyze maternal and neonatal complication of pregestational diabetes mellitus and gestational diabetes mellitus, and to compare with the outcome METHOD: The study included 108 pregnancies with diabetes mellitus among 8,495 admitted to the Department of Obstetrics and Gynecology, Catholic University of Korea Medical College, Holy Family Hospital from January 1, 1995 to December 31, 1998. The pregnancies were divided into pregestational diabetes mellitus group and gestational diabetes mellitus group. The data were analyzed and reviewed retrospectively based on medical records RESULTS: 1) Incidence of maternal complication in gestational diabetes mellitus was 7% of pregnancy induced hypertension, 3% of pyelonephritis, 1% of retinopathy and 1% of chronic hypertension. In case of pregestational diabetes mellitus, 18% of pregnancy induced hypertension, 5% of nephropathy, 9% of retinopathy and 14% of pyelonephritis. 2) Incidence of neonatal complication in gestational diabetes mellitus was 1% of congenital malformation, 1% of shoulder dystorcia, 7.3% of polyhydramnios, 17.7% of hyperbilirubinemia, 40.6% of hypoglycemia and 1% of FDIU. In case of pregestaional diabetes mellitus, 1% of congenital malformation, 18.2% of polyhydramnios, 22.7% of hyperbilirubinemia, 27.3% of hypoglycemia, 18.6% of RDS and 4.6% of FDIU. 3) The outcomes of the treatment of pregestational diabetes; There was no significant difference in the maternal weight gain, neonatal birth wight but the incidence rates of neonatal complication was lower in case of insulin treatment 4) The outcomes of the treatment of gestational diabetes; There was significant difference in the maternal weight gain, neonatal birth weight and the incidence rates of maternal and neonatal complication was decreased in case of treatment. CONCLUSION: Incidence of maternal complication and perinatal complication was higher in pregestaional diabetes mellitus compared with gestational diabetes mellitus, so strict control of blood glucose level and education for diabetes mellitus were essential before gestation. And the proper treatment of gestational DM was necessary because maternal weight gain during pregnancy, neonatal birth weight and the maternal and neonatal complication were affected by treatment.