Diagnostic protocol for gestational diabetes mellitus (GDM) (IADPSG/ADA, 2011): influence on the occurrence of GDM and mild gestational hyperglycemia (MGH) and on the perinatal outcomes.

BACKGROUND: In August 2011, the Specialized Center for Diabetes and Pregnancy of the Botucatu Medical School/Unesp adopted a new diagnostic protocol for gestational diabetes mellitus, recommended by the American Diabetes Association and the International Association of the Diabetes and Pregnancy Study Group. The glycemic profile was evaluated using the 75-g oral glucose tolerance test (OGTT) used to diagnose mild gestational hyperglycemia, recognized and treated in our department as gestational diabetes mellitus. The cost-effectiveness of the new guidelines and the continued need for the evaluation of the glycemic profile, as part of our Service protocol, are controversial and require further investigation. We aimed to assess the impact of the new guidelines on the evaluation of mild gestational hyperglycemia and gestational diabetes mellitus, the incidence of adverse perinatal outcomes, and the association between the 75-g OGTT and the glycemic profile for the diagnosis of mild gestational hyperglycemia. METHODS: This cross-sectional study was performed identifying a convenience sample of pregnant women and their newborns. The women used our Service for diagnostic procedures, prenatal care and delivery, both before (January 2008 to August 14, 2011) and after (August 15, 2011 to December 2014) the protocol modification. The following variables were compared, following stratification according to diagnostic protocol: prevalence of gestational diabetes mellitus and mild gestational hyperglycemia, newborns large for gestational age, macrosomia, first cesarean delivery, and newborn hospital stay. Statistical analysis was performed using Poisson regression, the Student's t test, the Chi square or Fisher's exact test and risk estimate. The statistical significance threshold was set at 95% (p < 0.05). RESULTS: The new protocol resulted in an 85% increase in the number of women with GDM, but failed to identify 17.3% of pregnant women classified as having mild gestational hyperglycemia, despite a normal 75-g OGTT. The new guidelines did not affect perinatal outcome. CONCLUSIONS: These results support the validity of maintaining the glycemic profile as part of the diagnostic protocol at our hospital. Large multicenter studies with an adequate sample size are required for conclusive evidence on the cost-effectiveness of the new protocol.

Espiralização, estenose e trombose do cordão umbilical e morte fetal / Hypercoiling, stricture, and thrombosis of the umbilical cord and fetal death

Anormalidades do cordão umbilical são inúmeras, desde nós falsos, que não tem significado clínico, até alterações que determinam a morte fetal intraútero. Aqui apresentamos o caso de uma paciente que foi acompanhada em regime de pré-natal de baixo risco, com queixa de parada súbita da movimentação fetal.

Umbilical cord abnormalities are numerous, ranging from false knots, which have no clinical significance, to changes that often lead to fetal death. As prenatal ultrasound becomes increasingly sophisticated, many of these conditions are now diagnosed in uterus. We describe the case of a patient that progressed from a low-risk pre-natal condition, with a complaint of sudden cessation of fetal movement, to a diagnosis of fetal death.