Prognóstico obstétrico de pacientes portadoras de diabetes mellitus pré-gestacional / Pregnancy outcomes in women with pre-existing diabetes

OBJETIVO: Avaliar as alterações epidemiológicas, de perfil clínico e de prognóstico obstétrico em pacientes portadoras de diabetes mellitus pré-gestacional. MÉTODOS: Estudo retrospetivo (coorte) de todas as gestações simples, com diagnóstico de diabetes prévio que foram seguidas num centro com apoio perinatal diferenciado entre 2004 e 2011 (n=194). Analisaram-se tendências relacionadas com dados demográficos e variáveis clínicas maternas, dados de indicadores de cuidados pre-concepcionais e durante a gravidez, e de controle metabólico. Dados do parto como a idade gestacional (IG) do parto, via do parto e peso do neonato foram variáveis também estudadas. RESULTADOS: A frequência global de diabetes prévia, durante o período estudado, foi de 4,4 por mil, não se verificando variações significativas durante o período de estudo. Os casos de diabetes tipo 2 permaneceram constantes. Em 67% dos casos o parto foi de termo (máximo de 80% em 2010 - 2011), registrou-se uma redução significativa dos partos por cesárea eletiva (p=0,03) e na incidência de neonatos considerados grandes para a IG (p=0,04) ao longo dos anos em estudo. Apesar dos bons resultados relacionados com o controle metabólico ao longo da vigilância da gravidez não foi registrada nenhuma melhora ao longo do tempo. Da mesma forma a proporção de gestantes diabéticas com avaliação pre-concepcional permaneceu pouco animadora. CONCLUSÕES: O seguimento de gestantes portadoras de diabetes mellitus em unidades multidisciplinares parece permitir um ajuste metabólico tão precoce quanto possível, de forma a conseguir melhorar o prognóstico obstétrico. A melhora nos cuidados pré-concepcionais continua sendo um desafio.

PURPOSE: To describe trends in prevalence, indicators of care and pregnancy outcomes for women with pre-existing type I or type II diabetes. METHODS: Cohort study of all consecutive singleton pregnancies complicated by pre-existing type I or type II diabetes followed from 2004 to 2011 at a tertiary perinatal care centre (n=194). We collected data from the medical records and described trends in demographics, clinical history, indicators of care before or during pregnancy and glycaemic control. We also studied perinatal outcomes, including gestational age at delivery, mode of delivery, and birthweight. RESULTS: The overall incidence of pregestational diabetes was 4.4 per 1000, with no significant changes throughout the study period. The number of type 2 diabetes cases also remained constant. In 67% of cases delivery occurred after 37 weeks (maximum 80% in 2010 - 11). During this period there was a significant reduction in rates of elective caesarean section (p=0.03) and in the incidence of large infants for gestational age (p=0.04). Indicators of glycaemic control were favorable throughout pregnancy, with no significant trends detected during the study period. However, preconceptional care indicators were substandard, with no significant improvement. CONCLUSIONS: A multidisciplinary approach to diabetic management and obstetric practice contributed to adequate glycaemic control throughout pregnancy and to improved pregnancy outcomes. Preconceptional care remains a key challenge.

[Diabetes in pregnancy - postpartum screening]. / Diabetes gestacional - rastreio pós-parto.

INTRODUCTION: One third of women with gestational diabetes mellitus (GDM) will have diabetes or impaired glucose metabolism at postpartum screening. OBJECTIVE: Evaluate the percentage of women submitted postpartum screening and associate the result with maternal history. METHODS: Retrospective investigation of 1013 pregnancies with GDM (2005-2009). We divided the population into two groups according to the result: normal (group 1) and with diabetes or impaired glucose metabolism (group 2). For both groups we evaluated maternal age, body mass index, weight gain during pregnancy, need for insulin therapy, risk factors for GDM, and newborn weight. RESULTS: Postpartum screening was achieved in 76.8% of women (n=778). The test was considered normal (group 1) in 628 women (80.7%) and modified (group 2) in 150 women (19.3%). Group 2 had older women (median age 34 vs. 33 years; p-value 0.013), higher body mass index (28.5 vs. 25.8kg/cm2; p-value 0.000), more women with diabetes mellitus family history in first degree (50.3% vs. 39.9%; p-value 0.026) and prior personal history of macrosomia (12.1% vs 5.4%; p-value 0.003). Earlier diagnosis of GDM was also made in this group (27 vs. 31 weeks; p-value 0.000) and a higher percentage had made insulin therapy (41% vs. 15%; p-value 0.000), having started earlier (28 vs 30 weeks; p-value 0.010). There was a higher percentage of multiparous pregnant in group 2 (64% vs 49.4%; p-value 0.001) and a larger number of cases of newborns large for gestational age (17.1% vs 8.3%; p-value 0.001). Personal history of GDM and weight gain during pregnancy was similar in both groups. CONCLUSIONS: Women who test abnormal in postpartum screening are usually older, heavier, multiparous, with a family related to DM patients and prior personal history of macrosomia. GDM diagnosis is made earlier in pregnancy, more often they need insulin therapy started ealier and there was a higher number of newborns large for gestational age.

[Pregnancy outcomes in women with pre-existing diabetes]. / Prognóstico obstétrico de pacientes portadoras de diabetes mellitus pré-gestacional.

PURPOSE: To describe trends in prevalence, indicators of care and pregnancy outcomes for women with pre-existing type I or type II diabetes. METHODS: Cohort study of all consecutive singleton pregnancies complicated by pre-existing type I or type II diabetes followed from 2004 to 2011 at a tertiary perinatal care centre (n=194). We collected data from the medical records and described trends in demographics, clinical history, indicators of care before or during pregnancy and glycaemic control. We also studied perinatal outcomes, including gestational age at delivery, mode of delivery, and birthweight. RESULTS: The overall incidence of pregestational diabetes was 4.4 per 1000, with no significant changes throughout the study period. The number of type 2 diabetes cases also remained constant. In 67% of cases delivery occurred after 37 weeks (maximum 80% in 2010 - 11). During this period there was a significant reduction in rates of elective caesarean section (p=0.03) and in the incidence of large infants for gestational age (p=0.04). Indicators of glycaemic control were favorable throughout pregnancy, with no significant trends detected during the study period. However, preconceptional care indicators were substandard, with no significant improvement. CONCLUSIONS: A multidisciplinary approach to diabetic management and obstetric practice contributed to adequate glycaemic control throughout pregnancy and to improved pregnancy outcomes. Preconceptional care remains a key challenge.

Acute myocardial infarction in the puerperium.

The authors describe the case of a forty-two-year-old patient with acute myocardial infarction (MI) on the third day of puerperium, who underwent direct angioplasty. The authors review the main physiological cardiovascular and hemostatic changes in pregnancy, which are usually well tolerated but which increase the probability of cardiovascular events when risk factors or previous cardiac disease are associated. Blood volume and cardiac output increase by around 50% during pregnancy, hemoglobin concentration falls, and reduced peripheral vascular resistance leads to a fall in arterial blood pressure during the first half of pregnancy. End-diastolic pressure, stroke volume and cardiac output increase in the immediate puerperium, and cardiovascular risk is highest in the perinatal period. The incidence of MI during pregnancy and puerperium is low; however, it is on the increase due to the growing number of pregnancies in women close to the end of their reproductive age.