Obesity, gestational weight gain, and birth weight in women with gestational diabetes: the LINDA-Brasil (2014-2017) and the EBDG (1991-1995) studies

ABSTRACT Objective: This study aimed to evaluate gestational weight gain and birth weight in women with gestational diabetes mellitus of two Brazilian cohorts enrolled three decades apart. Methods: The authors compared data of 2362 women from the Lifestyle INtervention for Diabetes Prevention After Pregnancy study (LINDA-Brasil, 2014-2017) to those of 359 women from the Estudo Brasileiro de Diabetes Gestacional study (EBDG, 1991-1995). Gestational weight gain was classified by the 2009 Institute of Medicine criteria; large and small for gestational age newborns, by the Intergrowth-21st chart. Differences in birth weight means between pregestational BMI and gestational weight gain categories were evaluated by ANOVA; the associations of gestational weight gain and birth weight, through multivariable Poisson regression. Results: In LINDA-Brasil, women presented higher pregestational body mass index (30.3 ± 6.5 vs. 24.6 ± 4.4 kg/m2) and were frequently obese (46.4 vs. 11.1%) compared to those of the EBDG. In the EBDG, gestational weight gain was larger (11.3 ± 6.1 vs. 9.2 ± 7.6 kg) and rates of small for gestational age higher (7.5 vs. 4.5%) compared to LINDA-Brasil. In LINDA-Brasil, excessive gestational weight gain was associated to macrosomia (adjusted relative risk [aRR]: 1.59, 95% CI 1.08-2.35) and large for gestational age (aRR: 1.40; 95% CI 1.05-1.86); less gain increased the risk of low birth weight (aRR: 1.66; 95% CI 1.05-2.62) and small for gestational age (aRR: 1.79; 95% CI 1.03-3.11). These associations were similar in the EBDG, although not statistically significant. Conclusions: Improvements in gestational weight gain and rates of small for gestational age occurred over time in gestational diabetes mellitus pregnancies, accompanied by a worsening in maternal weight profile. This highlights the nutritional transition during this period and the importance of avoiding excessive gestational weight gain as well as promoting adequate weight before conception.

Impact of overweight and obesity on pregnancy outcomes in women with gestational diabetes - results from a retrospective multicenter study

ABSTRACT Objective The aim of this study was to evaluate the impact of pre-pregnancy body mass index (BMI) on pregnancy outcomes in women with gestational diabetes (GD). Subjects and methods Retrospective multicenter study using data from the Portuguese National Register. We included women with GD with a singleton pregnancy. GD diagnosis was according to the International Association of the Diabetes and Pregnancy Study Group criteria. Women were divided into groups according to their pre-pregnancy BMI: < 18.5 kg/m2 (underweight), ≥ 18.5 and < 25.0 kg/m2 (normal weight), ≥ 25 and < 30 kg/m2 (overweight) and ≥ 30 kg/m2 (obese). Results We included 3,103 pregnant women with GD, 29.6% (n = 918) were overweight and 27.3% (n = 846) were obese. Compared to normal weight, the overweight and obese groups had a higher percentage of gestational hypertension (4.0% and 8.5% vs. 2.1%), cesarean delivery (32.8% and 41.3% vs. 27.9%), macrosomia (3.9% and 6.7% vs. 2.4%), and large for gestational age (LGA) newborns (8.3% and 13.5% vs. 6.0%). Obesity increased the risk of gestational hypertension (OR 4.5, p < 0.001), preeclampsia (OR 1.9, p = 0.034), cesarean delivery (OR 2.0, p < 0.001), macrosomia (OR 3.1, p < 0.001) and LGA (OR 2.3, p < 0.001). Conclusion In pregnant women with GD, pregnancy complications increase with pre-pregnancy BMI. In obese women, appropriate diet and counseling prior to gestation and more aggressive medical intervention during pregnancy are needed in order to prevent macrosomic and LGA newborns and to reduce maternal complications.

Comparison of maternal and fetal outcomes in parturients with and without a diagnosis of gestational diabetes / Comparação de desfechos maternos e fetais entre parturientes com e sem o diagnóstico de diabetes gestacional

Abstract Objective The present study aims to compare the maternal and fetal outcomes of parturients with and without a gestational diabetes diagnosis. Methods A case-control study including parturients with (cases) and without (control) a gestational diabetes diagnosis, who delivered at a teaching hospital in Southern Brazil, between May and August 2018. Primary and secondary data were used. Bivariate analysis and a backward conditionalmultivariate logistic regression were used to make comparisons between cases and controls, which were expressed by odds ratio (OR), with a 95% confidence interval (95%CI) and a statistical significance level of 5%. Results The cases (n=47) weremore likely to be 35 years old or older compared with the controls (n=93) (p<0.001). The cases had 2.56 times greater chance of being overweight (p=0.014), and a 2.57 times greater chance of having a positive family history of diabetes mellitus (p=0.01). There was no significant difference regarding weight gain, presence of a previous history of gestational diabetes, height, or delivery route. The mean weight at birth was significantly higher in the infants of mothers diagnosed with diabetes (p=0.01). There was a 4.7 times greater chance of macrosomia (p<0.001) and a 5.4 times greater chance of neonatal hypoglycemia (p=0.01) in the infants of mothers with gestational diabetes. Conclusion Therefore, maternal age, family history of type 2 diabetes, obesity and pregestational overweightness are important associated factors for a higher chance of developing gestational diabetes.

Resumo Objetivo O presente estudo tem como objetivo comparar os desfechos maternos e fetais das parturientes com e sem diagnóstico de diabetes gestacional. Métodos Estudo caso-controle, incluindo parturientes com (casos) e sem (controle) diagnóstico de diabetes gestacional, que tiveram parto em um hospital de ensino no Sul do Brasil, entre maio e agosto de 2018. Foram utilizados dados primários e secundários. Análise bivariada e regressão logística multivariada condicional retrógrada foram utilizadas para fazer comparações entre casos e controles, expressas por razão de probabilidades (RP), com intervalo de confiança de 95% (IC95%) e nível de significância estatística de 5%. Resultados Os casos (n=47) tiveram maior chance de ter idade superior a 35 anos em comparação com os controles (n=93) (p<0,001), chance 2,56 vezes maior de estarem acima do peso (p=0,014), e chance 2,57 vezes maior de terem história familiar positiva de diabetes mellitus (p=0,01). Não houve diferença significativa relacionada ao ganho de peso, história pregressa de diabetes gestacional, estatura ou via de parto. O peso médio ao nascer foi significativamente maior nos lactentes de mães com diabetes gestacional (p=0,01). Houve 4,7 vezes maior chance de macrossomia (p<0,001), e 5,4 vezes maior chance de hipoglicemia neonatal (p=0,01) em lactentes de mães com diabetes gestacional. Conclusão Portanto, idade materna, história familiar de diabetes tipo 2, obesidade e excesso de peso pré-gestacional são importantes fatores associados a uma maior chance de desenvolvimento de diabetes gestacional.

Predictors of excess birth weight in Brazil: a systematic review / Preditores do excesso de peso ao nascer no Brasil: revisão sistemática

Abstract Objective: To describe the main predictors for excess birth weight in Brazilian children. Data sources: Systematic review carried out in the bibliographic databases: PubMed/MEDLINE, Cochrane, Scopus, Web of Science, and LILACS. The research in the gray literature was performed using the Google Scholar database. The bias risk analysis was adapted from the Downs and Black scale, used to evaluate the methodology of the included studies. Data synthesis: Using the classifications of fetal macrosomia (>4.000 g or ≥4.000 g) and large for gestational age (above the 90th percentile), 64 risk factors for excess birth weight were found in 33 scientific articles in the five regions of the country. Of the 64 risk factors, 31 were significantly associated with excess birth weight, with excess gestational weight gain, pre-gestational body mass index ≥25 kg/m2, and gestational diabetes mellitus being the most prevalent. Conclusion: The main predictors for excess birth weight in Brazil are modifiable risk factors. The implementation of adequate nutritional status in the gestational period and even after childbirth appears to be due to the quality and frequency of the follow-up of the mothers and their children by public health agencies.

Resumo Objetivo: Descrever os principais preditores para o excesso de peso ao nascer em crianças brasileiras. Fontes dos dados: Revisão sistemática feita nos bancos de dados bibliográficos: PubMed/Medline, Cochrane, Scopus, Web of Science e Lilacs. A pesquisa na literatura cinzenta foi feita na base de dados Google Acadêmico. A análise do risco de viés foi adaptada da escala de Downs e Black, usada para avaliar a metodologia dos estudos incluídos. Síntese dos dados: Com o uso das classificações macrossomia fetal (> 4.000 g ou ≥ 4.000 g) e grande para idade gestacional acima do percentil 90, foram encontrados 64 fatores de risco para excesso de peso ao nascer em 33 artigos científicos nas cinco regiões do país. Dos 64 fatores de risco, 31 foram significativamente associados a excesso de peso ao nascer, os mais prevalentes foram ganho de peso gestacional excessivo, índice de massa corporal pré-gestacional ≥25 kg/m2 e diabetes mellitus gestacional. Conclusão: Os principais preditores para o excesso de peso ao nascer no Brasil são fatores de risco modificáveis. O estabelecimento de um estado nutricional adequado no período gestacional e mesmo após o parto parece ser a qualidade e a frequência do acompanhamento dos órgãos de saúde junto às mães e seus filhos.

Effectiveness of insulin analogs compared with human insulins in pregnant women with diabetes mellitus: systematic review and meta-analysis / Efetividade dos análogos da insulina comparados às insulinas humanas em gestantes com diabetes mellitus: Revisão sistemática com metanálise

Abstract Diabetes during pregnancy has been linked to unfavorable maternal-fetal outcomes. Human insulins are the first drug of choice because of the proven safety in their use. However, there are still questions about the use of insulin analogs during pregnancy. The objective of the present study was to determine the effectiveness of insulin analogs compared withhuman insulin in the treatment of pregnant women with diabetes througha systematic review withmeta-analysis. The search comprised the period since the inception of each database until July 2017, and the following databases were used:MEDLINE, CINAHL, EMBASE, ISIWeb of Science, LILACS, Scopus, SIGLE andGoogle Scholar.We have selected 29 original articles: 11 were randomized clinical trials and 18 were observational studies.We have explored data from 6,382 participants. All of the articles were classified as having an intermediate to high risk of bias. The variable that showed favorable results for the use of insulin analogs was gestational age, with a mean difference of - 0.26 (95 % confidence interval [CI]: 0.03-0.49; p = 0.02), but with significant heterogeneity (Higgins test [I2] = 38%; chi-squared test [χ2] = 16.24; degree of freedom [DF] = 10; p = 0.09). This result, in the clinical practice, does not compromise the fetal well-being, since all babies were born at term. There was publication bias in the gestational age and neonatal weight variables. To date, the evidence analyzed has a moderate-to-high risk of bias and does not allow the conclusion that insulin analogs are more effective when compared with human insulin to treat diabetic pregnant women.

Resumo Diabetes durante a gestação tem sido relacionado a desfechos materno-fetais desfavoráveis. As insulinas humanas são a primeira escolha medicamentosa, devido à comprovada segurança no seu uso. Entretanto, ainda há questionamentos sobre o uso dos análogos da insulina na gestação. O objetivo do presente estudo foi determinar a efetividade dos análogos da insulina comparados às insulinas humanas no tratamento de gestantes com diabetes por meio de uma revisão sistemática com metanálise. A busca compreendeu desde o início de cada base de dados até julho de 2017, e foi realizada nos seguintes bancos de dados: MEDLINE, CINAHL, EMBASE, ISI Web of Science, LILACS, Scopus, SIGLE e Google Scholar. Selecionamos 29 artigos originais, sendo 11 ensaios clínicos randomizados e 18 estudos observacionais. Exploramos dados de 6.382 participantes. Todos os artigos foram classificados como sendo de intermediário a alto risco de viés. A variável que demonstrou resultado favorável ao uso dos análogos da insulina foi idade gestacional, com uma diferençamédia de - 0.26 (95% índice de confiança [IC]: 0.03-0.49; p = 0.02), porém com heterogeneidade significativa (teste de Higgins [I2] = 38%; teste do qui quadrado [χ2] =16.24; graus de liberdade [GL] =10; p = 0.09). Esse resultado, na prática clínica, não compromete o bem-estar fetal, uma vez que todos os bebês nasceram a termo. Houve viés de publicação nas variáveis idade gestacional e peso neonatal. Até o momento, as evidências analisadas possuem um risco de viés moderado a elevado e não permitem concluir que os análogos da insulina sejam mais efetivos em comparação às insulinas humanas para tratar gestantes diabéticas.

A systematic review and meta-analysis of gestational weight gain recommendations and related outcomes in Brazil

Worldwide, different guidelines are used to assess the adequacy of gestational weight gain. This study identified the recommendations for gestational weight gain in Brazilian women. We also determined the proportion of women with adequate weight gain in accordance with these recommendations and the associated perinatal outcomes. A systematic review was performed. A computerized search was conducted utilizing the following databases: PubMed, MEDLINE, Web of Science, Embase, SciELO and Google Scholar. Observational studies of healthy, Brazilian, pregnant women were included. Studies were excluded if they did not provide pregestational weight and gestational weight gain or if they studied women with comorbid conditions. A meta-analysis was performed to evaluate the odds ratio of inadequate (insufficient or excessive) gestational weight gain. Seventeen studies were included in the systematic review and four studies were included in the meta-analysis. The most widely used recommendations were from the Institute of Medicine. Excessive gestational weight gain was associated with fetal macrosomia and high rates of cesarean delivery. Overweight women had a higher risk of excessive gestational weight gain than eutrophic women (OR=2.80, 95%CI=2.22-3.53). There are no standardized recommendations concerning gestational weight gain based on Brazilian population-based data. Many Brazilian women are overweight or obese at the beginning of pregnancy. Overweight pregnant women have a higher risk of excessive gestational weight gain. Excessive gestational weight gain was associated with cesarean delivery and fetal macrosomia.

Prevalencia y factores de riesgo asociados a macrosomía fetal en recién nacidos del Hospital Nacional Daniel Alcides Carrión durante el periodo Enero - Diciembre 2009 / Prevalence and risk factors associated with fetal macrosomia in neonates of the National Hospital Daniel Alcides Carrion during the period January - December 2009

Objetivos: Determinar los factores de riesgo asociados a macrosomía fetal en recién nacidos del Hospital Nacional Daniel Alcides Carrión entre Enero y Diciembre del año 2009. Material y Métodos: La investigación es de tipo analítico con casos control, retrospectivo e incluye a todos los pacientes con macrosomía del cual se ha obtenido una muestra, con una cantidad similar de casos control que se ha realizado en el Hospital Daniel Alcides Carrión del Callao entre Enero a Diciembre del año 2009. Resultados: En el año 2009 en el Hospital Nacional Daniel Alcides Carrión el total de recién nacidos fue de 6447, de ellos se tomó la muestra de 130 macrosómicos. La prevalencia fue de 6,23 por ciento de recién nacidos macrosómicos. El 67 por ciento (87) fue masculino y el 33 por ciento (43) fue femenino, las razones por las cuales se da una predominancia pero aún con los esfuerzos realizados no llegamos a determinar la razón de ese fenómeno, que consideramos sea un tema específico de investigación. El sexo se distribuye proporcionalmente entre los casos y controles, al igual que la talla materna definida en >=160 y <160 cm, el control prenatal en <= 4 y >4 controles. La presencia de infección del tracto urinario (ITU), vulvovaginitis (VV), preeclampsia (PE), oligoamnios (OLIGOAM), ruptura prematura de membranas (RPM) y antecedente de diabetes (ANT DM) es similar proporcionalmente en casos y controles. (p>0,05). La obesidad se distribuye en mayor proporción en los casos que en los controles (56,4 por ciento vs 37,2 por ciento). Conclusiones: En general los resultados encontrados en el presente estudio coinciden con otros estudios similares realizados en otros países y en el Perú. La incidencia de macrosomía al nacer que se encontró fue de 6,23 por ciento, en el Hospital Nacional Daniel Alcides Carrión entre Enero a Diciembre del 2009.

La hipótesis de Pedersen no es suficiente: Otros nutrientes además de la glucosaexplicarían la macrosomía fetal enpacientes diabéticas gestacionales consobrepeso y buen control glicémico / Nutrients other than glucose might explain fetal overgrowth in gestationaldiabetic pregnancies

Since 1964, the hypothesis of Pedersen has been used to explain fetal macrosomia observed in gestational diabetes mellitus (GDM), by a mechanism involving maternal hyperglycemia - fetal hyperglycemia - fetal hyperinsulinemia. However,since the 1980-89 decade, it is known that pregnant women with pre-gestationaloverweight not suffering from GDM still have a higher frequency of fetal macrosomia. Furthermore, pregnant women with GDM, despite being subjected to optimalglycemic control, still show unacceptably high frequencies of fetal macrosomia, aphenomenon that is concentrated in pregnancies with overweight or obesity priorto pregnancy. If glucose is not the single nutrient responsible for fetal macrosomiain pregnant women with gestational diabetes that undergo strict glycemic control,other nutrients may cause excessive fetal growth in pre-pregnancy overweightmothers. In this review, we propose that triglycerides (TG) could be responsible forthis accelerated fetal growth. If this hypothesis is validated in animal models andclinical studies, then normal and pathological ranges of TG should be defined, andmonitoring of triglyceride levels during pregnancy should be advised as a possiblenew alternative, besides a good glycemic control, for the management of fetal macrosomia in GDM women with overweight prior to pregnancy.

La obesidad materna y el recién nacido macrosómico en el Instituto Especializado Materno Perinatal, Lima 2003-2005 / Maternal obesity and the newborn with macrosomia in the Specialized Institute Materno Perinatal, Lima 2003-2005

OBJETIVO: Determinar la relación entre la obesidad al inicio, en el segundo y tercer trimestre del embarazo y los recién nacidos macrosómicos atendidos en el Instituto Nacional Materno Perinatal durante el periodo 2003-2005. MATERIAL Y METODOS: Se realizo un estudio analítico, prospectivo en la cual se siguió a dos cohortes de gestantes, la primera gestantes con adecuado peso pregestacional o sobrepeso y la segunda gestantes con obesidad materna pregestacional. Se procedió a recolectar datos de la gestante, según su peso al inicio del control prenatal y subsiguientes controles, hasta el parte con registros del resultado neonatal. Posteriormente se determino la influencia entre el peso materna en el segundo y tercer trimestre con el resultado macrosómico del recién nacido. Se procedió al análisis descriptivo, a través de porcentajes, promedios y desviaciones estándar. Para la determinación de las pruebas de hipótesis se procedió a estadísticas inferenciales significativos con un nivel de significación estadística alfa menor a 0,05. Para la determinación de la influencia se procedió a la utilización del Riesgo Relativo (RR) con sus intervalos de confianza al 95 por ciento. RESULTADOS: La obesidad al inicio, en el segundo y tercer trimestre del embarazo se encontró fuertemente relacionada con los recién nacidos macrosómicos, así mismo la talla materna y la ganancia de peso en el 2do y 3er trimestre. CONCLUSION: La ganancia de peso en el tercer y segundo trimestre durante la gestación influye más en el peso del recién nacido independientemente del peso pregestacional.

Relación entre la ganancia del peso materno y la macrosomía fetal en el Hospital Nacional Arzobispo Loayza. Lima - Perú. Julio 2010 - Junio 2011 / Relationship between the maternal weight gain and fetal macrosomia at the National Hospital Arzobispo Loayza. Lima - Peru. July 2010 - June 2011

Objetivos: Determinar la relación la ganancia de peso de la madre y el nacimiento de un feto macrosómico con peso mayor o igual a 4000 g en el Servicio de Obstetricia del Hospital Nacional Arzobispo Loayza. Material y métodos: Se realizó un estudio observacional, diseño retrospectivo, transversal. Se revisaron 263 historias clínicas de pacientes recién nacidos vivos atendidos en el Servicio de Obstetricia del Hospital Nacional Arzobispo Loayza, nacidos entre el 01 de Julio del 2010 al 31 de Junio del 2011 y que registraron un peso mayor o igual a 4000 gramos, y que tuvieran sus datos completos consignados en la historia clínica materna y libro de registro. Resultados: La prevalencia de nacimientos macrosómicos en el Hospital es de 6.22 por ciento. Hubo diferencias estadísticamente significativas en relación al peso habitual, las obesas tenían una media del peso habitual de 80.2+/-6kilos, y las que tuvieron peso ideal pregestacional tuvieron una media de 58.6+/-5.7 kilos. También observamos que las pacientes con obesidad pregestacional tuvieron recién nacidos de 4343.9+/-206.8 gramos, mucho más en relación a las pacientes con peso ideal[4179.3+/-268.5] y con sobrepeso [4113.8+/-118.4]. Observamos que las pacientes con variación ponderal mayor de 10 kilos tuvieron recién nacidos con un mayor peso [4222.2+/-218.6 versus 4171.7+/-250.6 gramos] sin haber una diferencia estadísticamente significativa [P>0.05]. Conclusiones: Existe relación entre la ganancia de peso de la madre (>10 kilos) y el nacimiento de un feto macrosómico con peso mayor o igual a 4200 g en el Servicio de Obstetricia del Hospital Nacional Arzobispo Loayza. Los recién nacidos del sexo femenino muestran asociación con el peso al nacer mayor de 4500 gramos [P<0.05]. En los pacientes neonatos con más de 4500 gramos encontramos que en las gestantes hubo una mayor edad [31.8+/-3.3 versus 29.2+/-5.8 años], y mayor número de gestaciones [4 versus 2] [P<0.05].

Maternal and fetal leptin level correlation with fetal macrosomia

Leptin seems to be a critical factor for overall fetal development. Macrosomia may place the mother and fetus or neonate at risk for adverse outcomes. To test if leptin level is implicated in macrosomia. The sample comprised 25 cases delivered full term normal weight infants, and 25 cases delivered full term macrosomicinfants. Maternal serum samples and fetal cord samples were withdrawn immediately after birth of the full term infants. Fetal leptin level was higher in macrosomic infants than normal weight infants. No difference in maternal leptin level between both groups was observed. Leptin levels related directly to quantity of body fat tissue in fetal macrosomia as there is leptinresistence causing elevated leptin levels

Marcadores clínicos e bioquímicos de gravidade do diabetes mellitus gestacional / Clinical and biochemical markers of gravity of gestational diabetes mellitus

O diabetes mellitus gestacional (DMG) é uma patologia da segunda metade da gestação caracterizada por uma insulinorresistência que está intimamente relacionada ao resultado perinatal adverso e se não diagnosticada e tratada pode trazer sérios problemas tanto para a mãe quanto para o feto. O objetivo deste trabalho foi realizar uma revisão da literatura sobre marcadores clínicos e bioquímicos de gravidade do DMG. Trata-se de uma revisão de literatura nas bases de dados PubMed, SciELO e Cochrane. Foram selecionados 50 artigos, mas apenas 25 tiveram relevância para serem discutidos nesta revisão. Após análise pôde-se concluir que com os novos critérios-diagnósticos e um aumento na incidência dessa patologia é de grande valia identificar marcadores clínicos e bioquímicos que estão relacionados aos resultados perinatais adversos e à necessidade de tratamento complementar à dieta

The gestational diabetes mellitus (GDM) is a second half of pregnancy disease characterized by insulin resistance that is closely related to perinatal outcome and if undiagnosed and untreated can cause serious problems for both mother and fetus. The objective of this study was to review the literature on clinical and biochemical markers of GDM severity. This is a literature review in PubMed, SciELO and Cochrane. Fifty articles were selected, but only 25 were relevant to be discussed in this review. After their analysis it was concluded that with the new diagnostic criteria and an increased incidence of this pathology is of great value to identify clinical and laboratory markers that are related to adverse perinatal outcomes and the need to supplement the diet treatment

Association between maternal and fetal weight gain: cohort study / Associação entre o ganho de peso materno e fetal: estudo de coorte

CONTEXT AND OBJECTIVE: Excessive gestational weight gain is related to many complications (both maternal and fetal), such as macrosomia. The most common complications in macrosomic fetuses include: increased risk of intrauterine death, need for intensive care, fractures, neonatal hyperbilirubinemia, paralysis of the brachial plexus and obesity in childhood and adulthood. The aim of this study was to evaluate the association between gestational and fetal weight gain and the incidence of macrosomia in two maternity hospitals. DESIGN AND SETTING: Cohort study in two public maternity hospitals in Goiânia, Brazil. METHODS: This was a cohort study on 200 healthy pregnant women with normal body mass index, divided into two groups: one with normal weight gain and the other with excessive weight gain during pregnancy. RESULTS: The cohorts were similar regarding maternal age, per capita income, schooling level and reproductive behavior. The fetal weight was greater in the cohort with excessive maternal weight gain (3,388.83 g ± 514.44 g) than in the cohort with normal weight (3,175.86 g ± 413.70 g) (P < 0.01). The general incidence of macrosomia was 6.5%: 13.0% (13 cases) in the cohort with excessive maternal weight gain and 0.0% (0 cases) in the cohort with adequate weight gain. CONCLUSION: Excessive maternal weight gain was associated with increased fetal birth weight and incidence of macrosomia.

CONTEXTO E OBJETIVO: O ganho de peso gestacional excessivo está relacionado a inúmeras complicações tanto maternas como fetais, como por exemplo, a macrossomia. Esta, por sua vez, pode aumentar o risco de morte intra-uterina, necessidade de cuidados intensivos, fraturas, hiperbilirrubinemia neonatal, paralisia do plexo braquial e obesidade na infância e fase adulta. O objetivo deste estudo foi avaliar a associação do ganho de peso gestacional com o ganho de peso fetal e a incidência de macrossomia em duas maternidades. TIPO DE ESTUDO E LOCAL: Estudo de coorte em duas maternidades públicas em Goiânia, Brasil. MÉTODOS: Estudo de coorte com 200 gestantes saudáveis com índice de massa corporal normal, divididas em dois grupos, um com ganho de peso adequado e o outro com peso excessivo na gravidez. RESULTADOS: As coortes foram semelhantes quanto à idade materna, renda per capita, escolaridade e comportamento reprodutivo. O peso fetal foi maior na coorte de ganho de peso materno excessivo (3388,83 g ± 514,44 g) do que na de peso normal (3175,86 g ± 413,70 g) (P < 0,01). A incidência geral de macrossomia foi 6,5% sendo de 13,0% (13 casos) na coorte com ganho de peso materno excessivo e de 0,0% (0 casos) na de peso adequado. CONCLUSÃO: O ganho de peso materno excessivo esteve associado ao aumento do peso fetal ao nascer e à incidência de macrossomia.

Diabetes gestacional: como tratar?: [revisão] / Gestational diabetes: how to treat?: [review]

O diabetes gestacional está associado a aumento do risco de complicações para o binômio materno-fetal e sua incidência é crescente. O tratamento específico é recomendado para reduzir complicações durante a gravidez, o parto e a vida adulta. O objetivo principal desta revisão foi pesquisar evidências acerca das opções de tratamento do diabetes gestacional, incluindo monitoramento glicêmico, dieta, exercícios físicos e, para algumas pacientes, farmacoterapia e conduta obstétrica específica, como antecipação do parto. A insulinoterapia é efetiva e segura, sendo considerada como o padrão-ouro de tratamento. Atualmente, são limitados os dados que embasam o uso dos análogos da insulina de ação prolongada durante a gravidez, porém, experiências recentes mostraram segurança da utilização do análogo de ação rápida lispro. Alguns estudos randomizados controlados têm demonstrado resultados promissores sobre a segurança e a eficácia dos antidiabéticos orais gliburida e metformina no tratamento das gestantes diabéticas. No entanto, devido a preocupações de longo prazo, maiores estudos randomizados controlados com metodologias comparáveis e, consequentemente, novas meta-análises serão necessárias para confirmar a segurança e a eficácia dessas drogas durante a gravidez e aumentar a sua aceitação na comunidade médica. O efeito do parto eletivo (indução ou cesárea) no prognóstico gestacional permanece indefinido.

Gestational diabetes is associated with an increased risk of complications both for the mothers and for her children, and its incidence has increased. Specific treatment is recommended in order to reduce risks during pregnancy, birth and adult life. This review's main objective was to analyze the evidences of the options for treatment of gestational diabetes, including glycemic monitoring, diet, physical exercises and, for some patients, pharmacotherapy and specific obstetric management such as anticipation of delivery. Insulin therapy is both effective and safe, qualities that make it the gold standard of treatment. Nowadays, there are limited data to support the use of long-acting insulin analogs, but recent studies reported that the rapid-acting analog lispro is safe. Some randomized controlled trials have demonstrated promising findings regarding safety and efficacy of the oral antidiabetics glyburide and metformin used for the treatment of diabetic pregnancies. However, because of long-term concerns, larger randomized controlled trials with comparable methodologies and, consequently, new meta-analysis are needed to confirm the safety and efficacy of these drugs during pregnancy and to gather widespread acceptability in the medical community. The effect of labor induction or elective cesarean on pregnancy prognosis remains unclear.

Obesidade e complicações gestacionais / Obesity and pregnancy complications

A população de obesos entre as mulheres na menacme tem aumentado de maneira assustadora nos últimos anos. A consequência é o aumento da incidência de gestantes obesas com elevado risco cardiometabólico e sujeitas a intercorrências perigestacionais. A assistência pré-natal nesse grupo de gestantes é precária devido à falta de equipe multidisciplinar preparada e material adequado. O profissional que assiste a gestante obesa deve ter como objetivo principal prevenir e intervir em tempo hábil nas intercorrências às quais mãe e feto estão sujeitos durante o período perigestacional. Ele deve estar livre de preconceitos e tentativas exageradas e inadequadas de perda de peso durante a gestação da paciente. O alvo principal da abordagem multidisciplinar é o preparo da gestante para mudança de seu estilo de vida familiar sabendo que a obesidade é uma doença de transmissão interpessoal de hábitos. A associação de riscos potenciais para mãe e feto à obesidade é bem estabelecida, mas o conhecimento desses riscos e a condução da gestação de maneira adequada são pouco praticados. O presente artigo buscou contribuir para melhora da assistência pré-natal das gestantes obesas juntamente com a criação de grupos multidisciplinares para condução dessas pacientes.

The obese population between women in the mecname has been grown in a concerned manner in the past few years and its consequence is the growth of the obese pregnant patients with high cardio metabolic risk and subject to clinical intercurrences. The prenatal assistance in this pregnant group is precarious due to a lack of a prepared multidisciplinary group and also an adequate work material. The professional whom takes care of an obese patient shall be as the main purpose the prevention and intervention in a timely manner in the clinical intercurrences which mother and fetus are subject to during the gestational period. His method shall be free of prejudices, inadequate and exaggerated attempts to loss of weight during the patient pregnancy. The main target of the multidisciplinary approach is the pregnant patient's prepare to a new familiar lifestyle keeping in mind that obesity is a sickness of interpersonal habit transmission. The association of potential risks to mother and fetus during obesity is well determined but the knowledge of those risks and the pregnancy conduction in a proper manner are few practiced. The present article wanted to contribute to an improvement of prenatal assistance of obese pregnant jointly with a multidisciplinary group creation to conduct those patients.

Fatores relacionados à presença de recém-nascidos grandes para a idade gestacional em gestantes com diabetes mellitus gestacional / Factors related to the presence of large for gestational age newborns in pregnant women with gestational diabetes mellitus

OBJETIVO: avaliar os fatores relacionados à presença de recém-nascidos grandes para a idade gestacional nas gestantes com diabetes mellitus gestacional. MÉTODOS: no período de janeiro de 2004 a julho de 2006, foram selecionadas, retrospectivamente, 157 gestantes que apresentavam diabete mellitus gestacional e estavam em acompanhamento. Esse grupo foi dividido em dois subgrupos: um com recém-nascidos de peso adequado para a idade gestacional (n=136) e outro com recém-nascidos grandes para a idade gestacional (n=21). Foram comparadas as características maternas nos dois grupos. Para a análise da hipótese de igualdade entre a média dos dois grupos, utilizou-se o teste t de Student. E para que se testasse a homogeneidade dos grupos em relação às proporções, foi utilizado o teste do χ2. RESULTADOS: os grupos não apresentaram diferença significativa quanto à idade materna, índice de massa corporal, ganho de peso durante a gestação, número de gestações anteriores, glicemia de jejum no teste oral de tolerância à glicose após a ingestão de 75 g (TOTG 75 g), idade gestacional no momento do parto, valores glicêmicos durante o tratamento e o tipo de tratamento utilizado (p>0,05). No grupo com recém-nascidos grandes para a idade gestacional, observou-se valor de glicemia de duas horas no TOTG 75 g maior (p=0,02), a idade gestacional de início de tratamento maior (p=0,02), e um número menor de consultas realizadas no serviço (p<0,01). Ajustando-se a um modelo de regressão logística, foi encontrado, no valor da glicemia de duas horas do TOTG 75 g, o fator de maior importância (p<0,01) na predição de recém-nascidos grandes para a idade gestacional. CONCLUSÕES: os fatores que se relacionam melhor com a ocorrência de recém-nascidos grandes para a idade gestacional foram o início tardio do tratamento e, consequentemente, o menor número de consultas e, principalmente, o maior valor da glicemia de duas horas no TOTG 75 g.

PURPOSE: to evaluate factors related to the presence of neonatal macrosomia in pregnant women with gestational diabetes mellitus. METHODS: 157 pregnant women presenting gestational diabetes mellitus in follow-up were retrospectively selected from January 2004 to July 2006. This group has been divided into two subgroups: one with newborns with weight in accordance with the gestational age (n=136) and another with macrosomic newborns (n=21). Maternal characteristics have been compared between the groups. The t-Student test was used for the analysis of equality hypothesis between the averages of the two groups, and chi-square test, to check the groups' homogeneity concerning ratios. RESULTS: the groups did not show any significant difference concerning the gestational age, body mass index, weight gain along the gestation, number of previous pregnancies, fast glycemia in the oral glucose tolerance test after the ingestion of 75 g (TOTG 75 g), gestational age at delivery, glycemic values during the treatment, and the type of treatment used (p>0.05). In the group with neonatal macrosomia, there was a higher two-hour-glycemia in the TOTG 75 g (p=0.02), higher gestational age at the treatment onset (p=0.02), and a lower number of appointments at the health service (p<0.01). When adjusted to a logistic regression model, the most important factor (p<0.01) found to predict neonatal macrosomia was the two-hour-glycemia in the TOTG 75 g. CONCLUSIONS: the factors more frequently related to neonatal macrosomia were late treatment onset and, consequently, lower number of appointments and chiefly, high two-hour-glycemia in the TOTG 75 g.

Obesidade e gestação: aspectos obstétricos e perinatais / Obesity and pregnancy: obstetric and perinatal aspects

A obesidade na gestação acarreta diversas complicações maternas, fetais e neonatais. As pacientes obesas estão sujeitas a alterações hormonais, respiratórias, circulatórias e digestórias, além da maior frequência de partos cesarianos e mortalidade materna, sendo que 80% desta frequência está associada à anestesia. As complicações fetais e neonatais são variadas e incluem macrossomia fetal, prematuridade, morte perinatal, defeitos congênitos, natimortos e aumento da admissão em Unidade de Tratamento Intensivo. Apesar de avanços nos equipamentos, a avaliação ultrassonográfica é limitada em gestantes obesas, dificultando o rastreamento das anomalias fetais. Embora a prevenção seja a estratégia ideal para controle da obesidade, nenhum programa de prevenção primária foi ainda executado com sucesso. A única alternativa eficaz é o tratamento da obesidade como prevenção de suas complicações, informando às pacientes os grandes riscos de sua gestação. Quando não for possível realizar este tratamento, são necessários maiores cuidados no pré-natal, parto e pós-parto. O presente artigo objetiva realizar atualização sobre as complicações maternas e fetais em gestantes obesas, bem como sobre o seu manejo.

Obesity in pregnancy is the cause of maternal, fetal and neonatal complications. Obese patients are more susceptible to hormonal, respiratory, circulatory and digestive alterations, and besides, it is more frequent cesarean deliveries and maternal death, being 80% associated with anesthesia. There are lots of fetal and maternal complications, including fetal macrossomy, prematurity, perinatal death, congenital defects, birth deaths and increasing in Intensive Care Unit. In spite of the equipment's advancement, ultrassonographic evaluation is limited in obese pregnant women, becoming more difficult the diagnosis of fetal anomalies. Prevention is the ideal strategy to control obesity; however, there is no efficient primary prevention successfully realized. The only alternative is the treatment of obesity to prevent its complications, telling the patients about the great risks of their pregnancies. When it is not possible to realize this treatment, it is necessary more careful in antenatal, delivery and after delivery. The objective of the present article is to make an actual revision about maternal and fetal complications in obese pregnant women and its follow-up and treatment.

Gestational weight gain and fetal birth weight in rural regions of Rasht / Iran

Proper nutrition during pregnancy is essential for optimal fetal growth. Investigation of the relation between pregnancy weight gain and birth weight in rural regions of Rasht, center of Guilan Province in Iran, was the purpose of this study. In this cohort study, prenatal data of 918 women who attended local health centers with singleton term pregnancies were recorded. Maternal demographic characteristics, anthropometric measurements, total pregnancy weight gain and birth weight were recorded by health workers. The women were stratified based on their pre-pregnancy body mass index [BMI] into four groups: underweight women, women with normal weight, overweight women and obese women. The relation between weight gain and low birth weight [LBW, birth weight <2500 g] and macrosomia [birth weight >4000 g] was studied in these four groups. Data were analyzed using Chi-square test, independent t-test, Pearson correlation and logistic regression with 95% confidence intervals. More than 50% of underweight women and women with normal weight and almost 30% of overweight and obese women gained weight less than what is mentioned in the Institute of Medicine [IOM] recommendations. The incidence rate of LBW was 7.1% and that of macrosomia was 5%. Mean weight gain of women with LBW was significantly less than mean weight gain of women who had an infant with a birth weight more than 2500 g [P=0.002]. Women who gained weight less than the recommended range had higher rate of LBW in their infants [P=0.01] and the incidence of macrosomia in women with a weight gain above the recommended weight was higher than that in others [P=0.012]. Pregnancy weight gain less than what is mentioned in the IOM guideline was the only predictor for LBW [OR=2.79, CI=1.16-6.73, P=0.02]. Pregnancy weight gains less than what is mentioned in the IOM recommendation was a significant predictor of LBW, regardless of pre-pregnancy BMI

Diabetes melito tipo 1 e gestação: [revisão] / Type 1 diabetes mellitus and pregnancy: [review]

As gestações em mulheres com diabetes têm apresentado resultados que melhoraram dramaticamente nas últimas décadas, em razão dos progressos com a monitorização das glicemias e administração de insulina. A gravidez nas mulheres com diabetes tipo 1 está associada a aumento de risco tanto para o feto quanto para a mãe. Antes da concepção, a prioridade é normalizar a glicemia para prevenir malformações congênitas e abortamentos espontâneos. Com o progresso da gestação, a mãe tem um risco aumentado de hipoglicemias e cetoacidose. Mais tarde existe risco de piora na retinopatia, hipertensão induzida pela gestação, pré-eclâmpsia-eclâmpsia, infecções de trato urinário e poliidrâmnios. No final da gestação, existe o risco de macrossomia e morte súbita intra-uterina do feto. Todas essas complicações podem ser prevenidas ou, pelo menos, minimizadas pelo planejamento da gestação e pelo controle intensivo das oscilações das glicemias, mantendo-as próximo ao normal.

As a result of the advances in glucose monitoring and insulin administration, there has been a dramatic improvement in the outcomes of pregnancy in diabetic women over the past decades. Pregnancy in type 1 diabetic women is associated with an increase in risk both to the fetus and to the mother. The normalization of blood glucose in order to prevent congenital anomalies and spontaneous abortions is considered a priority. As the pregnancy progress, the mother is at an increased risk for hypoglycemia or diabetic ketoacidosis. Later in the pregnancy, she is at risk of accelerated retinopathy, pregnancy-induced hypertension and preeclampsia-eclampsia, urinary tract infection, and polyhydramnios. At the end of pregnancy, there is also an increased risk of macrosomia and sudden death of the fetus in uterus. All of these complications can be prevented or, at least, minimized with careful planning of the pregnancy and intensive tight glucose control.

Gestational diabetes and its association with unpleasant outcomes of pregnancy

Diabetes Mellitus account for over 8% of all pregnancies and is associated with increased risk of complications of pregnancy, and prenatal mortality. This study was conducted to determine the disadvantages of gestational diabetes on mother and her baby, in order to prevent neonatal and marital unpleasant outcomes. The present historical cohort study includes 420 mothers referred to Shiraz hospitals in 2006. Seventy cases with diabetes and 350 were controls. Data was collected by questionnaire and analyzed by t-test and fisher exact tests in SPSS v.13 software. The recurrence rate of gestational diabetes was 72.4%. There was a significant difference between the two groups in still birth [RR= 8.87], macrosommia [RR= 7.38], respiratory distress [RR= 5.16], hypoglycemia [RR= 13.38], neonatal jaundice [RR= 3.28], need for respiratory support [RR= 3.17], congenital anomalies [RR= 7.28] and cesarean delivery [RR= 1.96] [p<0.05]. However it did not show any significant difference in intra uterine growth retardation [IUGR], shoulder dystocia, breech labor, need for insulin, meconium problems, induction of labor, episiotomy and placenta disorders [P>0.05]. Stillbirth, macrosomia, respiratory distress, hypoglycemia and neonatal jaundice are more common in women with gestational diabetes. Hence in view of the unfavourable outcome, preventive measures and control of diabetes are essential