Medically assisted reproduction in Italy, 2020 data from the Italian MAR Register.

BACKGROUND: The Italian Medically Assisted Reproduction (MAR) Register (ItMARR) was established by the Decree of the Minister of Health issued on October 7th, 2005. ItMARR has a crucial role in clearly and publicly disseminating epidemiological information on the MAR activities and outcomes. METHODS: ItMARR data is collected in aggregate form and is mandatory as set out in Law 40/2004. The aim of this article is to make a snapshot of the authorized centers that perform IUI and ART in Italy. Data used in this article refer to MAR treatments started between January 1st and December 31st, 2020. RESULTS: MAR techniques were performed by 332 centers. In total, 67,927 ART cycles and 12,171 IUI cycles were performed in 2020. Gametes donation cycles represent 12.9% of ART activity and 4.0% of IUI. ART cycles performed per million women of childbearing age was 6525. In 2020, 2.5% of births in the general population in Italy were a result of application of ART techniques. MAR activity in 2020, has been heavily reduced by the limitations to reproductive treatment due to SARS-CoV-2 pandemic. Pregnancy rates per transfers were 26.7% with fresh techniques, 32.6% with FER, 25.7% with FO, 38.0% with OD and 39.1% with SD. There were fewer multiple deliveries than the previous year. CONCLUSIONS: The ItMARR, has become a great asset in the reproductive health scenario promoting a better MAR information dissemination. ItMARR is working on the implementation towards a "cycle-by-cycle" data collection system. This will bring the Italian monitoring system in line with others European countries.

Na(+), K(+), Cl(-), acid-base or H2O homeostasis in children with urinary tract infections: a narrative review.

Guidelines on the diagnosis and management of urinary tract infections in childhood do not address the issue of abnormalities in Na(+), K(+), Cl(-) and acid-base balance. We have conducted a narrative review of the literature with the aim to describe the underlying mechanisms of these abnormalities and to suggest therapeutic maneuvers. Abnormalities in Na(+), K(+), Cl(-) and acid-base balance are common in newborns and infants and uncommon in children of more than 3 years of age. Such abnormalities may result from factitious laboratory results, from signs and symptoms (such as excessive sweating, poor fluid intake, vomiting and passage of loose stools) of the infection itself, from a renal dysfunction, from improper parenteral fluid management or from the prescribed antimicrobials. In addition, two transient renal tubular dysfunctions may occur in infants with infectious renal parenchymal involvement: a reduced capacity to concentrate urine and pseudohypoaldosteronism secondary to renal tubular unresponsiveness to aldosterone that presents with hyponatremia, hyperkalemia and acidosis. In addition to antimicrobials, volume resuscitation with an isotonic solution is required in these children. In secondary pseudohypoaldosteronism, isotonic solutions (such as 0.9 % saline or lactated Ringer) correct not only the volume depletion but also the hyperkalemia and acidosis. In conclusion, our review suggests that in infants with infectious renal parenchymal involvement, non-renal and renal causes concur to cause fluid volume depletion and abnormalities in electrolyte and acid-base balance, most frequently hyponatremia.

Impacto do diabetes gestacional nos desfechos neonatais: uma coorte retrospectiva / Impact of gestational diabetes on neonatal outcomes: a retrospective cohort study

Objetivos: Avaliar os desfechos neonatais em gestantes diagnosticadas com diabetes mellitus gestacional (DMG). Métodos: Coorte retrospectiva com 522 puérperas, sendo 255 pacientes com diagnóstico de DMG pelos critérios da International Association of the Diabetes and Pregnancy Study Groups (IADPSG) e 267 pacientes sem DMG, tendo sido este último grupo selecionado por sorteio. Foram avaliadas associações entre DMG e a ocorrência de desfechos neonatais adversos, entre os quais prematuridade, peso excessivo para a idade gestacional, índice de Apgar baixo, hipoglicemia neonatal e internação em unidade de tratamento intensivo neonatal. Além disso, variáveis maternas como idade, índice de massa corporal pré-gestacional, ganho de peso, paridade e via do parto, foram avaliadas para ajuste de confundimento. Uma vez confirmada a normalidade de distribuição das características estudadas, foi usado o teste T para as variáveis quantitativas e o teste qui-quadrado para as qualitativas. Para avaliar o impacto do DMG nos resultados perinatais, foram calculados os riscos relativos a partir de tabelas de contingência e foram construídos modelos de regressão de Poisson com variação robusta para ajustar as variáveis de confundimento.Resultados: Os recém-nascidos das gestantes com DMG apresentaram maior risco de prematuridade (risco relativo [RR] 2,3; intervalo de confiança [IC] 95% 1,1-5,0), peso excessivo para a idade gestacional (RR 1,6; IC95% 1,1-2,5) e hipoglicemia neonatal (RR 4,2; IC95% 1,4-12,3). As associações entre DMG e escores baixos de Apgar no primeiro e no quinto minuto não se mostraram significativas: RR 1,9; IC95% 0,9-3,8 e RR 2,1; IC95% 0,4-11,3, respectivamente. Não houve aumento do risco de internação em unidade de tratamento intensivo neonatal dos recém-nascidos de gestantes diabéticas (RR 1,4; IC95% 0,6-3,2).Conclusões: Na amostra estudada, os riscos de prematuridade, peso do recém-nascido excessivo para a idade gestacional e hipoglicemia foram maiores nos recém-nascidos de gestantes com DMG diagnosticada pelos critérios da IADPSG.

Aims: To assess neonatal outcomes in pregnant women with positive diagnosis of gestational diabetes mellitus (GDM).Methods: Retrospective cohort study of 522 postpartum women, among whom 255 presented with GDM, diagnosed in accordance with the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria, and 267 did not have GDM. The patients in the latter group were randomly selected. Associations were established between GDM and adverse neonatal outcomes, including prematurity, macrosomia, low Apgar score, neonatal hypoglycemia, and admission to a neonatal intensive care unit. Maternal characteristics such as age, pre-gestational body mass index, weight gain, parity, and mode of delivery were also analyzed for the adjustment of confounding factors. After confirming the normal distribution of the assessed characteristics, the quantitative variables were analyzed by Student's t test and the qualitative ones by the chi-squared test. The data on the effect of GDM on perinatal outcomes were presented as relative risks using contingency tables, and robust Poisson's regression models were used to adjust the confounding variablesResults: Newborn infants of women with GDM had a higher risk of preterm birth (relative risk [RR] 2.3; 95% confidence interval [95%CI] 1.1-5.0), macrosomia (RR 1.6; 95%CI 1.1-2.5), and neonatal hypoglycemia (RR 4.2; 95%CI 1.4-12.3). The relationship between GDM and low one-minute and five-minute Apgar scores was not significant (RR 1.9; 95%CI 0.9-3.8 and RR 2.1; 95%CI 0.4-11.3, respectively). There was no significant increased risk of admission to the neonatal intensive care unit (RR 1.4; 95%CI 0.6-3.2).Conclusions: The risks of prematurity, macrosomia, and neonatal hypoglycemia were higher in pregnant women with GDM diagnosed according to the IADPSG criteria.

Perinatal impact of the use of metformin and glyburide for the treatment of gestational diabetes mellitus.

OBJECTIVE: To evaluate the perinatal impact of metformin and glyburide in the treatment of gestational diabetes mellitus (GDM). METHODS: A randomized clinical trial conducted from July 2008 until September 2010 studied 200 pregnant women with GDM who required adjunctive therapy to diet and physical activity. Patients were randomized to use metformin (n=104) or glyburide (n=96). The drugs were replaced by insulin when they reached the maximum dose without glycemic control. Assessed outcomes: weight and neonatal blood glucose. RESULTS: No difference was found (P>0.05) between the groups regarding maternal age, gestational age at inclusion, body mass index, glucose levels in oral glucose tolerance test (OGTT) 75 g and glycemic control. Difference was found in the number of previous pregnancies (2.84 vs. 2.47, P=0.04) and weight gain during pregnancy (7.78 vs. 9.84, P=0.04) in the metformin group and glyburide respectively. The perinatal results showed no difference (P>0.05) in the percentage of cesarean deliveries, gestational age at delivery, number of newborns large for gestational age (LGA), neonatal hypoglycemia, admission to intensive care unit and perinatal death. We found differences in weight (3193 g vs. 3387 g, P=0.01) and ponderal index (2.87 vs. 2.96, P=0.05) of newborns, and in neonatal blood glucose levels at the 1st (59.78 vs. 54.08, P=0.01) and 3rd h (61.53 vs. 55.89, P=0.01) after birth between the metformin and glyburide groups respectively. CONCLUSIONS: Weight and ponderal index were lower in the newborns of the metformin group; glucose levels (1st and 3rd h after birth) were lower in the glyburide group.

Hipoglicemiantes orais versus insulinoterapia no tratamento do diabete gestacional / Oral hypoglycemic agents versus Insulin in the treatment of gestational diabetes

OBJETIVOS: avaliar os melhores artigos publicados naliteratura médica acerca do tratamento do diabete mélitogestacional (DMG), verificando a eficácia das drogassobre o controle glicêmico e sua segurança quanto aosresultados perinatais. MÉTODOS: foi realizada busca noportal ?Pubmed? com a seguinte estratégia de busca:?Diabetes, gestational?, utilizando o limite quanto à presençados termos no título ou no resumo. No portal daBireme foi avaliada a literatura nacional e latino-americana,utilizando-se como descritor o termo ?Diabete gestacional?.Também foram incluídos 20 artigos não selecionadosnas bases de dados e constantes em referênciasbibliográficas e artigos clássicos de livros-texto. As referênciassão do período de 1979 até 2011. A revisão deuprioridade a estudos de ensaios clínicos randomizadose relacionados diretamente com o tema. RESULTADOS:a contra-indicação do uso dos hipoglicemiantes orais nagestação é baseada em estudos não controlados e compequena casuística, que mostram um efeito negativo sobrea morbimortalidade materno-fetal. Atualmente estãodisponíveis inúmeros estudos controlados, randomizadoscom grande número de pares avaliados, com eficácia dasdrogas sobre o controle glicêmico oscilando entre 53%e 96% e com resultados perinatais semelhantes entreinsulina, glibenclamida e metformina. CONCLUSÕES: oshipoglicemiantes orais retornam como excelente alternativaà insulinoterapia no tratamento do diabete mélitogestacional após avaliações randomizadas e controladasem número adequado de sujeitos.

PURPOSE: To evaluate the best articles published inmedical literature about the treatment of gestationaldiabetes mellitus (GDM), verifying the effectiveness ofdrugs on glycemic control and its safety regarding theperinatal outcomes. METHODS: We searched the portal?Pubmed? with the following search strategy: ?Diabetes,gestational?, the limit was the presence of thewords in the title or abstract. At the Bireme portal, wereviewed the national literature and latin American literature,using the descriptor ?Diabete gestacional?. Wealso included 20 articles that were not selected in thedatabases but were present at references and articlesof classic textbooks.The references are from the periodof 1979 to 2011.The review has given priority to clinicaltrials studies with direct relation to the subject.RESULTS:a contraindication to the use of oral hypoglycemicagents is based on uncontrolled studies and smallsample size, which show a negative effect on maternaland fetal morbidity and mortality. Currently there aremany randomized controlled trials with large numbersof pairs reviewed, with drug efficacy on glucose controlranging between 53% and 96% and similar perinataloutcomes with insulin, glibenclamide and metformin.CONCLUSIONS: oral hypoglycemic return as an excellentalternative to insulin therapy in the treatment of GDMafter randomized and controlled trial sin adequate numbersof subjects.

Impacto do IMC no tratamento e no resultado perinatal em pacientes com diabete melito gestacional / Impact of BMI in the treatment and perinatal outcome of patients with gestational diabetes mellitus

Objetivo: verificar os impactos do IMC, no tratamento e resultado perinatal, em pacientes com DMG. Material e métodos: foi realizado um estudo de coorte retrospectivo. Foram sujeitos deste estudo 258 gestantes portadoras de DMG e seus recém-nascidos, divididas em 4 grupos: baixo peso (IMC<18,5kg/m2), normopeso (IMC entre 18,5 e 24,9 kg/m2), sobrepeso (IMC25-29,9 kg/m2) e obesidade (IMC>ou=30 kg/m2). O estudo foi realizado no período de Janeiro de 2003 a março de 2008. Foram avaliados dados relacionados ao diabete e ao recém-nascido. Resultados: encontramos 10,1% de baixo peso, 63,9% normopeso, 12,4% sobrepeso e 13,6% obesas. Encontramos um aumento da média das glicemias em jejum coletadas em pacientes com IMC aumentado durante o tratamento (p=0,004), enquanto as pós-prandiais foram semelhantes (p=0,837). A necessidade do uso de insulina como terapia ocorreu independentemente do IMC da paciente (p=0,692), entretanto as doses de insulina aumentaram com o IMC (p=0,053). Referente às características do nascimento e do recém-nascido, não houve diferenças entre os 4 grupos. Conclusão: encontramos um aumento da média das glicemias em jejum coletadas durante o tratamento e da dose final de insulina conforme há aumento do IMC. Contudo, não observamos repercussões, relacionadas a esse índice, nos recém-nascidos.

Objective: to assess the impact of BMI in the treatment and perinatal outcome of patients with GDM. Methods: a retrospective cohort study was carried out. Participants of this study were 258 pregnant women suffering from GDM and their newborn infants. The women were divided into 4 groups: low (BMI <18.5 kg/m2), normal weight (BMI between 18.5 and 24.9 kg/m2), overweight (BMI 25-29, 9 kg/m2) and obesity (BMI> or = 30 kg/m2). The study was carried out from January 2003 to March 2008. Data related to diabetes and the newborn was evaluated. Results: patients were found to be 10.1% low weight, 63.9% normal weight, 12.4% overweight and 13.6% obese. According to the variables related to DMG, an increase in fasting blood glucose with TTOG and in fasting home glycemic control corresponded to an increase in BMI (p <0.05), but this has not occurred after 2hs TTOG or postprandial home glycemic control (p> 0.05). The need of using insulin as therapy occurred regardless of the patient?s BMI (p = 0692), however, insulin doses increased with BMI (p = 0053). Regarding characteristics of birth and the newborn, no differences between the 4 groups were found. Conclusion: as BMI increased, a rise in fasting blood glucose with TTOG, in fasting glycemia collected during treatment, and in the final dose of insulin was found. However, no effect in newborns was found in relation to this index.

Metformin compared with glyburide for the management of gestational diabetes.

OBJECTIVE: To assess blood glucose control and neonatal outcomes when women with gestational diabetes mellitus (GDM) were treated with metformin or glyburide. METHODS: When an appropriate diet was insufficient to control their blood glucose levels, women with GDM were randomized to a glyburide or a metformin treatment group. If the maximum dose was reached, the assessed drug was replaced by insulin. The primary outcome measures analyzed were maternal glucose levels during pregnancy, birth weight, and neonatal glucose levels. RESULTS: The only significant difference in outcome between the 2 treatment drugs was that maternal weight gain during pregnancy was less in the metformin (n=40) than in the glyburide group (n=32) (10.3 kg vs 7.6 kg; P=0.02). No differences were found in treatment failure, mean level of fasting or postprandial plasma glucose, rate of participants with glycated hemoglobin, birth weight, rate of large-for-gestational-age newborns, or newborns with hypoglycemia. CONCLUSION: The treatment of GDM with metformin or glyburide was found to be equivalent for both women and newborns.

Impacto do tratamento intensivo do diabetes melito gestacional no peso do recém nascido

Objetivo: Avaliar o impacto do tratamento intensivo do Diabetes Melito Gestacional (DMG) no peso do recém-nascido (RN). Métodos: Estudo de caso-controle com 311 gestantes. Destas, 179 gestantes foram diagnosticadas com DMG (grupo de estudo) e 132 constituíram o grupo controle. No grupo de estudo o tratamento empregado objetivou glicemia de jejum menor que 90mg/dl, glicemia pós-prandial menor que 120mg/dl e circunferência abdominal fetal menor que o percentil 75 para a idadegestacional. Os grupos foram comparados quanto aos desfechos maternos e neonatais. Foram considerados significativos valores de p<0,05. Resultados: As características maternas das duas populações apresentaram diferenças, a idade materna foi maior (p<0,01) e o ganho de peso durante a gestação foi menor (p<0,01) no grupo de estudo (DMG). Não foi encontrada diferença no número de gestações anteriores,no índice de massa corporal, na via de parto, e no Apgar do RN nos grupos. A idade gestacional ao nascimento (p<0,01), o peso do RN (p<0,01) e a presença de RNs GIG (p=0,03) foi maior no grupo controle. Foi encontrado um número maior de RNs pequenos para a idade gestacional (PIG) no grupo de estudo (DMG) (p=0,02). Conclusão: O tratamento intensivo do DMG diminuiu o peso fetal, prevenindo o aparecimento de RNs GIG, porém aumentou o número de RNs PIG.

Objective: Evaluate the impact of intensive treatment of gestational diabetes mellitus on newborn weight. Methods: Case control study involving 311 pregnant women. The study group was formed by 179 women diagnosed with gestational diabetes and 132 formed thecontrol group. The treatment used in the study group aimed, fasting plasma glucose <90 mg/dl, post-prandial glucose <120mg/dl and abdominal fetal circunference under 75 percentil for gestacional age. The groups were compared to maternal and fetal outcomes. Were considered significant values of p<0.05. Results: Maternal outcomes vary between groups, in the study group (diabetes mellitus gestacional) mother?s age was higher (p<0,01) and weight gain during pregnancy was lower (p<0,01). There were no difference between pregnancy parity,index of corporal mass, obstetric outcome or Apgar score between groups. Atbirth gestacional age (p<0,01), newborn weight (p<0,01) and the presence of large for gestacional age (p<0,01) were higher in control group. Increased number of small for gestacional age fetus(p=0,02) were found in the study group. Conclusion: Intensive treatment of gestacionaldiabetes lowered fetal weigth, preventing the apearence of large for gestacional age, however it increased the number of small for gestacional age.

Hipoglicemiantes orais na gestação: metformina versus glibenclamida / Oral hypoglycemic agents in pregnancy: metformin versus glyburide

O diabetes gestacional é uma patologia frequente durante a gestação e com graves repercussões perinatais. Seu tratamento visa bom controle glicêmico, por dieta e atividade física, quando ocorre falha nesta terapêutica inicial está indicada insulinoterapia. Atualmente, na literatura mundial, vários estudos apresentam uma alternativa, os hipoglicemiantes orais, que sempre foram contraindicados durante a gestação, devido ao aumento da incidência de malformações, hipoglicemia neonatal e óbito, resultados estes baseados em estudos com pequena casuística, em série de casos ou caso-controle. Revisando a literatura foram encontrados vários estudos randomizados, controlados, com um grande número de casos, comparando a glibenclamida e a metformina com a insulinoterapia, mostrando que estas drogas são eficazes no controle glicêmico e não diferem da insulinoterapia quanto às complicações perinatais.(AU)

Gestational diabetes is a common condition during pregnancy with serious perinatal outcomes. The management of this disease aims to achieve adequate blood glucose control, through diet and regular exercises, in its failure insulin therapy can be indicated. In current literature, several studies offer an alternative to insulin therapy: oral hypoglycemic agents. These have always been counter-indicated during pregnancy because of increased incidence of malformations, hypoglycemia and neonatal death. These results were based on small scale studies, series of cases or case-control studies. A review of literature has shown several randomized, controlled, large-scale studies comparing the use of glyburide and metformin with insulin therapy. These studies have shown that these drugs are effective in controlling blood glucose and do not differ from insulin therapy regarding perinatal complications.(AU)

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

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.

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.

Diabete Melito Gestacional: dose ideal de insulina utilizada durante o terceiro trimestre de gestação e resultados perinatais / Gestational Diabetes Mellitus: ideal insulin dose used in the third trimester of gestation

Objetivo: Avaliar a dose ideal de insulina utilizada no tratamento do diabete melito gestacional (DMG) durante o terceiro trimestre da gestação e os resultados perinatais. Métodos: Foram avaliados, retrospectivamente,prontuários e carteiras de pré-natal de 104 gestantes com diagnóstico de DMG, com gestação única, que necessitaramde insulinoterapia durante o terceiro trimestre. O período do estudo foi de agosto de 2005 até julho de 2006. Foi utilizada inicialmente 0,9UI/kg/dia, dividida em quatro tomadas ao dia, com doses iguais de insulina regular pré-prandial e NPH ao deitar. A dose foi ajustada conforme os resultados das glicemias capilares, considerandovalores normais: jejum 60-90mg/dl, 1 hora pósprandial 60-120mg/dl e 3 horas da manhã 70-100mg/dl.Resultados: A dose média total de insulina foi de 76,7UI (DP=24,6), utilizando uma média de 0,97UI/kg/dia (DP=0,22UI) para o controle glicêmico. A dose antes do café (AC) foi significantemente maior (p<0,01)que a dose antes do almoço (AA), antes do jantar (AJ) e ao deitar (AD). A dose AA não difere da dose AJ (p=0,07) e é maior que a dose ao deitar (p=0,01). A dose AC foi de 30%, AA 25%, AJ 24% e AD 21% da dose total. O peso médio dos recém-nascidos foi 3.237g (DP=424g), com 10,6% de grande para a idade gestacional (GIG) e 16,3% hipoglicemia neonatal. Não houveóbito perinatal. Conclusão: A dose mais adequada para esta população durante o terceiro trimestre de gestação foi de 0,97UI/kg/dia, com um excelente resultado perinatal.

Objective: To evaluate the insulin dose for the management of gestational diabetes mellitus (GDM) duringthe third trimester of gestation.Methods: A hundred and four promptuaries of single-gestation patients diagnosed GDM and who neededinsulin therapy during the third trimester were analysed retrospectively in the study. The study was carried outfrom August, 2005 to July, 2006. At first, 0,9UI/kg/day was used divided into four doses a day, with equal regularinsulin pre-prandial and NPH bed time doses. The dose was adjusted according capillary glicemy testing results, considering normal values: before breakfast (BB) 60-90mg/dl, 1 hour pos-prandial 60-120mg/dl and at 3a.m. 70-100mg/dl. Results: Total insulin dose was 76,7UI (DP: 24,6),using an average of 0,97UI/kg/day (DP=0,22UI) for glucose level control. The dose before breakfast (BB) wassignificantly higher (p<0,01) than the dose before lunch (BL), before dinner (BD) and bed time (BT). No differencewas found in the doses BL or before BD (p=0,77) and it´s higher than the dose BT (p=0,01). Doses were BB 30%, BL 25%, BD 24% and BT 21% of the totaldose. Average birth weight was 3237g (DP=424g), with 10,6% large for gestational age (LGA) and 16,3% neonatal hypoglycemia. No perinatal deaths were reported. Conclusion: The most adequate dose for this group duringthe third trimester of gestation was 0,97UI/kg/day, with an excelent perinatal result.

Fatores relacionados à insulinoterpia no diabete melito gestacional / Factors related to Insulin therapy on gestational diabetes mellitus

Objetivo: Avaliar as características das gestantes que necessitaram de insulinoterapia para o tratamentodo Diabete Gestacional. Métodos: Estudo retrospectivo descritivo. Foramselecionadas 231 gestantes com Diabete Gestacional, no período de janeiro de 2004 até julho de 2006, divididas em dois grupos, um que necessitou de insulinoterapia para controle glicêmico (n=78) e outro que utilizou apenas dietoterapia (n=173).Resultados: 33,8% das gestantes utilizaram insulina. A idade materna (p<0,01) e o número de gestaçõesanteriores (p<0,01) foram maiores no grupo que utilizou insulina, e a idade gestacional de início do tratamento(p=0,02) foi menor neste grupo. O índice de massa corporal, ganho de peso durante a gestação, as glicemiano teste de tolerância oral à glicose com 75 gramas não apresentaram diferença (p>0,05). Conclusão: As gestantes com idade elevada, maior número de gestações anteriores e com chegada mais precoce ao serviço são as que mais necessitaram insulina para controle glicêmico.

Purpose: To evaluate the characteristics of pregnant patients who required insulin therapy for Gestational Diabetes management. Methods: A descriptive retrospective study. Were chosen 231 pregnant woman with Gestational Diabetes, on period of January 2004 to July 2006, divided into two groups, one which required insulin therapy for glucose control (n=78) and another group that used only diet control (n=173). Results: 33,8% of patients used insulin. Maternal age (p<0,01) and number or previous pregnancies (p<0,01) were higher in the group using insulin and gestational age at start of treatment (p=0,02) was lower. Body mass index, weight gain during pregnancy, glucose on oral glucose tolerance test with 75 grams did not show difference (p>0,05). Conclusion: older pregnant patients, those withhigher number of previous pregnancies and earlier beginning of management were those who most needed insulin for glucose control.

Tratamento do diabetes mellitus gestacional com glibenclamida: fatores de sucesso e resultados perinatais / Gestational diabetes mellitus management with glyburide: factors of success and perinatal outcomes

OBJETIVO: identificar os fatores relacionados ao sucesso no tratamento do diabetes mellitus gestacional (DMG) com a glibenclamida e avaliar os resultados perinatais. MÉTODOS: estudo longitudinal, prospectivo, no qual foram incluídas, no período de agosto de 2005 até julho de 2006, 50 gestantes portadoras de DMG, que necessitaram de terapêutica complementar à dietoterapia e à atividade física, com feto apresentando circunferência abdominal (CA) normal à ultra-sonografia (abaixo do percentil 75). Foi mantida a glibenclamida até o parto, enquanto o controle glicêmico estivesse adequado e a CA fetal normal, sendo considerado um sucesso terapêutico. Na falta de controle glicêmico ou a CA fetal alterada, a terapêutica foi substituída por insulinoterapia, sendo considerada falha terapêutica. As gestantes foram divididas em dois grupos: um que obteve sucesso com a terapêutica (n=29) e outro, falha (n=21). Os resultados avaliados foram: sucesso terapêutico, características maternas e resultado perinatal. RESULTADOS: dos casos analisados, 58 por cento obtiveram sucesso com a glibenclamida. Não foi encontrada diferença (p>0,05) nos dois grupos quanto à idade materna, valores das glicemias no teste de tolerância oral à glicose com 75 g, índice de massa corpórea (IMC) materno, número de consultas no pré-natal e número de gestações anteriores. Ajustando-se a um modelo de regressão logística, encontramos que as gestantes com sucesso terapêutico tiveram o diagnóstico mais tardio (p=0,02) e menor ganho de peso durante a gestação (p<0,01). O resultado perinatal não diferiu nos dois grupos. CONCLUSÕES: as gestantes com diagnóstico mais tardio e com menor ganho de peso tiveram mais chance de obter sucesso no tratamento do DMG com a glibenclamida. A falha na tentativa de utilização da glibenclamida não alterou o resultado perinatal.

PURPOSE: to identify the factors related to successful gestational diabetes mellitus (GDM) management with glyburide and to evaluate perinatal outcomes. METHODS: prospective longitudinal study including 50 pregnant women with GDM who required complementary treatment to diet and physical activity, whose fetus presented normal abdominal circumference (AC) to ultrasound (pct<75). Study period was August 2005 to July 2006. Ultrasonography was carried out monthly. Glyburide was used until delivery, as long as glucose control was obtained and fetal AC was normal, being thus considered therapeutically successful. In case there was no glucose control or alteration in AC, management was switched to insulin therapy, being thus considered therapeutically unsuccessful. Pregnant women were divided into two groups: one therapeutically successful (n=29) and another therapeutically unsuccessful (n=21). The results evaluated were: therapeutic success, maternal characteristics and perinatal outcome. RESULTS: fifty-eight percent of the cases were successfully managed with glyburide. No difference was found (p>0.05) in either group, with regards to maternal age, glucose values at OGTT75g, maternal body mass index (BMI), number of pre-natal consultations, number of previous pregnancies. According to the logistic model of regression used, therapeutically successful pregnant patients had had a later diagnosis (p=0.02) and lower weight gain during gestation (p<0.01). Perinatal outcome did not differ in either group. CONCLUSIONS: patients with later diagnosis and lower weight gain are more likely to have successful GDM management with glyburide. Unsuccessful management with glyburide did not alter the perinatal outcome.

[Glibenclamide in the treatment for gestational diabetes mellitus in a compared study to insulin]. / Glibenclamida no tratamento do diabete melito gestacional em estudo comparado à insulina.

OBJECTIVES: To study glibenclamide as a treatment for gestational diabetes mellitus (GDM) and its impact on newborn birth weight and neonatal glycemia as compared to insulin. METHODS: A randomized and open-label clinical trial, conducted from October 1st, 2003 to March 8, 2005. Seventy-two pregnant women with gestational diabetes mellitus requiring drug therapy were randomized and allocated into two groups--insulin and glibenclamide. RESULTS: The general characteristics in both groups were similar, except for the results of the 75 g OGTT, which were higher in the glibenclamide group (p= 0.02). Maternal fasting and postprandial glucose levels presented no difference. Six (18.75%) pregnant women received the maximum dose of glibenclamide with no glycemic control. The birth weight was higher in the group treated with glibenclamide (p= 0.01), and the incidence of macrosomic newborns statistically different (p= 0.01). Neonatal hypoglycemia was more frequent (p= 0.01) in newborns of glibenclamide group, with one single case of persistent hypoglycemia. CONCLUSION: Glibenclamide can be the first line drug for glycemic control in most GDM patients. The birth weight and incidence of hypoglycemia were higher in the glibenclamide group, but with one single case of persistent hypoglycemia that required intravenous infusion of glucose.

Fibrinolytic dysfunction after gestation is associated to components of insulin resistance and early type 2 diabetes in latino women with previous gestational diabetes.

Among patients with metabolic syndrome (MS), atherosclerosis and abnormal fibrinolytic function are frequently present, mostly owing to an increase in plasminogen activator inhibitor-1(PAI-1). We analyze PAI-1 in pregnant women, both normal and with gestational diabetes (GDM) and postpartum regarding its correlation to MS surrogates. Clinical characteristics, glucose tolerance (100g-OGTT), lipids, PAI-1 antigen, insulin sensitivity (HOMA-S), and pancreatic beta-cell function (HOMA-B) were investigated in 34 women. Eleven had normal glucose tolerance (NGT) during pregnancy and 23 had GDM (all GAD antibodies-negative). All patients were studied at 28-34 weeks of gestation and 16-24 weeks after delivery (75 g-OGTT). Parameters of interest were determined using commercial test systems. During pregnancy, PAI-1 was not statistically different between NGT and GDM (47+/-25 ng/ml versus 47+/-28 ng/ml, p=0.9). After gestation, 19 (56%) women had NGT (11 of them from previous NGT group) and 15 (44%) had impaired glucose tolerance (IGT) or DM. The IGT (IGT+DM) group had higher PAI-1 (p=0.01), which did not decreased after delivery NGT-NGT before and after delivery (47+/-25 ng/ml versus 6+/-5 ng/ml; p<0.001), GDM-NGT (62+/-36 ng/ml versus 14+/-15 ng/ml; p=0.001) and GDM-IGT (39+/-20 ng/ml versus 27+/-23 ng/ml; p=0.15). PAI-1 levels were positively correlated (p<0.05) to total cholesterol (r(s)=0.37), triglycerides (r(s)=0.48), fasting plasma glucose (r(s)=0.52), 2-h plasma glucose in the OGTT (r(s)=0.58) and were negatively correlated (p<0.05) with HOMA-S (r(s)=-0.42) and HOMA-B (r(s)=-0.38). Fibrinolytic dysfunction is still present in GDM women and is associated with early development of IGT or T2DM. PAI correlated with surrogate markers of MS levels and may identify a group of women at risk for macroangiopathy.

Glibenclamida no tratamento do diabete melito gestacional em estudo comparado à insulina / Glibenclamide in the treatment for gestational diabetes mellitus in a compared study to insulin

OBJETIVOS: Estudar a glibenclamida no tratamento do diabete melito gestacional (DMG) e sua repercussão no peso e na glicemia do recém-nascido (RN), em comparação com a insulina. MÉTODOS: Ensaio clínico randomizado e aberto, realizado entre 1° de outubro de 2003 e 8 de março de 2005. Foram sujeitas 72 gestantes com DMG que necessitaram de terapêutica complementar, sendo randomizadas em dois grupos: insulina e glibenclamida. RESULTADOS: As características gerais nos grupos não apresentaram diferença estatística, com exceção dos resultados do TTOG 75 g, que apresentaram valores maiores no grupo da glibenclamida (p= 0,02). As glicemias médias maternas não apresentaram diferença. Seis (18,75 por cento) gestantes atingiram a dose máxima de glibenclamida sem o controle glicêmico. O peso dos RNs foi maior no grupo tratado com glibenclamida (p= 0,01), com diferença na incidência de macrossômico (p= 0,01). A hipoglicemia neonatal estava mais presente (p= 0,01) nos RNs do grupo da glibenclamida, porém com apenas um caso de hipoglicemia persistente. CONCLUSÃO: A glibenclamida pode ser a droga de escolha para tratamento do DMG na maioria das pacientes.

OBJECTIVES: To study glibenclamide as a treatment for gestational diabetes mellitus (GDM) and its impact on newborn birth weight and neonatal glycemia as compared to insulin. METHODS: A randomized and open-label clinical trial, conducted from October 1st, 2003 to March 8, 2005. Seventy-two pregnant women with gestational diabetes mellitus requiring drug therapy were randomized and allocated into two groups - insulin and glibenclamide. RESULTS: The general characteristics in both groups were similar, except for the results of the 75 g OGTT, which were higher in the glibenclamide group (p= 0.02). Maternal fasting and postprandial glucose levels presented no difference. Six (18.75 percent) pregnant women received the maximum dose of glibenclamide with no glycemic control. The birth weight was higher in the group treated with glibenclamide (p= 0.01), and the incidence of macrosomic newborns statistically different (p= 0.01). Neonatal hypoglycemia was more frequent (p= 0.01) in newborns of glibenclamide group, with one single case of persistent hypoglycemia. CONCLUSION: Glibenclamide can be the first line drug for glycemic control in most GDM patients. The birth weight and incidence of hypoglycemia were higher in the glibenclamide group, but with one single case of persistent hypoglycemia that required intravenous infusion of glucose.

Macrossomia: conseqüências e estratégias de prevenção / Macrosomia: results and preventions strategies

A macrossomia fetal tem crescente incidência, sendo relacionada ao sobrepeso materno, ganho de peso excessivo na gravidez e diabetes mellitus gestacional (DMG). A morbimortalidade materna e fetal elevada envolve fatores como hiperglicemia, hiperinsulinemia, presença de co-morbidades e complicações agudas e crônicas próprias do diabetes mellitus. A macrossomia tem repercussões fetais importantes, como o aumento do risco de óbito fetal e complicações como tocotraumatismo, distócias, hipoglicemia neonatal, miocardiopatia hipertrófica, malformações e trombose vascular. As conseqüências maternas observadas são: elevada taxa de cesárea, laceração perineal extensa, hemorragia pós-parto e tempo prolongado de hospitalização. Controle metabólico durante o pré-natal, dieta, exercícios físicos, uso de insulina e interrupção da gravidez com 38 semanas são estratégias utilizadas com o intuito de prevenir esta morbidade. O conhecimento dos fatores de risco possibilita o rastreio e diagnóstico precoce do diabetes gestacional para que, estabelecida uma terapêutica eficaz e individualizada, a grávida seja mantida em euglicemia, prevenindo assim, a ocorrência da macrossomia e suas implicações

Efficacy of cytology for the diagnosis of Chlamydia trachomatis in pregnant women

This study evaluated the effectiveness of Papanicolaou staining for the initial diagnosis of Chlamydial infection in pregnant women. A hundred thirteen patients were examined with a Papanicolaou test, independent of gestational age, parity or maternal age. Three endocervical samples were collected; the first two were collected with a brush (Cytobrush plus, Mediscand, Sweden) and the third with Ayre's spatula. The first specimen was used for McCoy cell culture and the other two were examined cytologically. Chlamydial infection was detected in 9 (7.9 percent) patients. Only one (0.8 percent) was diagnosed by cytological exam. The sensitivity and specificity of the cytological examination were 10 and 98 percent, respectively. The estimated positive predictive value was 33.3 percent and the negative predictive value was 92.7 percent. When Papanicolaou stain diagnosis suggests Chlamydia, a more specific complementary exam should be added to confirm infection; subsequently adequate treatment can be implemented, thereby preventing the frequent complications of untreated subclinical infections.

Efficacy of cytology for the diagnosis of Chlamydia trachomatis in pregnant women.

This study evaluated the effectiveness of Papanicolaou staining for the initial diagnosis of Chlamydial infection in pregnant women. A hundred thirteen patients were examined with a Papanicolaou test, independent of gestational age, parity or maternal age. Three endocervical samples were collected; the first two were collected with a brush (Cytobrush plus, Mediscand, Sweden) and the third with Ayre's spatula. The first specimen was used for McCoy cell culture and the other two were examined cytologically. Chlamydial infection was detected in 9 (7.9%) patients. Only one (0.8%) was diagnosed by cytological exam. The sensitivity and specificity of the cytological examination were 10 and 98%, respectively. The estimated positive predictive value was 33.3% and the negative predictive value was 92.7%. When Papanicolaou stain diagnosis suggests Chlamydia, a more specific complementary exam should be added to confirm infection; subsequently adequate treatment can be implemented, thereby preventing the frequent complications of untreated subclinical infections.