Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes.

OBJECTIVE: To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS: This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded. RESULTS: Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria. CONCLUSIONS: GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

Hypertensive disorders in pregnancy: frequency and associated factors in a cohort of Brazilian women.

OBJECTIVE: To evaluate the frequency of and risk factors associated with hypertensive disorders in general antenatal care in five distinct areas of Brazil. METHODS: We performed a cohort study of 4892 women enrolled in midpregnancy from 1991 to 1995. Patients were queried at enrollment about hypertension prior to pregnancy. Medical diagnoses of hypertensive disorders in pregnancy were abstracted from patient records. Hypertensive disorders in pregnancy were classified according to recommendations of the American College of Obstetrics and Gynecology (ACOG). RESULTS: Of 4892 women studied, 367 (7.5%) presented hypertensive disorders, 113 (2.3%) being preeclampsia/eclampsia and 198 (4.0%) chronic hypertension. Frequencies of superimposed preeclampsia/eclampsia and transitory hypertension were 0.5% and 0.7%, respectively. Greater brachial arm circumference was strongly associated both with preeclampsia/eclampsia and with chronic hypertension (threefold difference across extreme quartiles, p < or =0.001). In adjusted analyses, being older, black, and obese were important and statistically significant risk factors for chronic hypertension. Similarly, nulliparity was a statistically significant risk factor for preeclampsia/eclampsia, and tendencies toward increased risk were seen for older, black, and obese women in adjusted analyses. Preeclampsia/eclampsia and chronic hypertension were notably less frequent in Manaus, although regional differences were statistically significant only for chronic hypertension. CONCLUSIONS: Hypertensive disorders commonly complicate pregnancy in Brazilian women. Risk factors for these disorders appear similar to those reported in other countries. Use of an inappropriately sized cuff to measure blood pressure may result in many false-positive diagnoses in more obese women. The considerably lower frequency of hypertensive disorders found in Manaus, in the Amazon region, warrants further study.

Assessment of weight gain during pregnancy in general prenatal care services in Brazil.

Obesity is an emerging major health risk for women around the world. In this regard, little attention has been given to pregnancy, a moment of risk not only for major weight gain in these women, but also for macrosomia in their offspring. The objective of this study is to evaluate weight gain during pregnancy. Data pertains to a cohort of pregnant women attending general prenatal care clinics in six state capitals in Brazil, from 1991 to 1995. We studied women aged 20 years and over with singleton pregnancies and no diagnosis of diabetes outside pregnancy, enrolled at approximately 20 - 28 weeks of gestation. According to the Institute of Medicine criteria, 38% (95%CI: 36-40%) of the women studied gained less and 29% (95%CI: 28-31%) had more than the recommended total weight gain. These proportions vary according to pre-pregnancy nutritional status. Given the increasing epidemic of obesity, the high prevalence of overweight and obesity in Brazilian women prior to pregnancy, and the lack of achievement of recommended weight gain during pregnancy, more effective means of managing weight gain during pregnancy are necessary.

Short stature and gestational diabetes in Brazil. Brazilian Gestational Diabetes Study Group.

AIMS/HYPOTHESIS: To examine the association between maternal stature and gestational diabetes mellitus. METHODS: We studied a sample of 5564 consecutive Brazilian women 20 or more years old, who were pregnant for approximately 21-28 weeks, had no history of diabetes outside pregnancy and were attending general prenatal care units in six state capitals in Brazil from 1991 to 1995. We did a 2-h, 75-g oral glucose tolerance test, defining gestational diabetes by World Health Organisation criteria. RESULTS: Those in the shortest quartile of height (< or = 151 cm) had a 60% increase in the odds of having gestational diabetes, independently of prenatal clinic, age, global obesity, family history of diabetes, skin colour, referral pattern, waist circumference, parity, previous gestational diabetes, education, ambient temperature and gestational age compared with the tallest quartile [odds ratio (OR) = 1.60, p = 0.005]. This association was observed for those with above median values of skinfold thickness (OR = 1.74, p = 0.006) but not for those with below median values (OR = 1.22, p = 0.51). Associations of short stature with high 2-h glycaemia (> or = 7.8 mmol/l) (OR = 1.61, p = 0.005) were essentially the same as those for gestational diabetes. There was, however, no association between short stature and gestational hyperglycaemia when the latter was defined exclusively by fasting values (OR = 0.97, p = 0.90). CONCLUSION/INTERPRETATION: In Brazil short stature associates with gestational diabetes, principally in women with greater fat mass. This difference in glycaemic levels is present postprandially but not in the fasting state.

Fasting plasma glucose is a useful test for the detection of gestational diabetes. Brazilian Study of Gestational Diabetes (EBDG) Working Group.

OBJECTIVE: To evaluate fasting plasma glucose as a screening test for states of gestational diabetes. RESEARCH DESIGN AND METHODS: Baseline data of a cohort conducted in general prenatal care units in Brazil, enrolling 5,579 women aged > or = 20 years with gestational ages of 24-28 weeks at the time of testing and no previous diagnosis of diabetes. A standardized 2-h 75-g oral glucose tolerance test was performed in 5,010 women. Gestational diabetes and its subcategories--diabetes and impaired glucose tolerance--were defined according to the 1994 World Health Organization panel recommendations. We evaluated screening properties of calculated sensitivity and specificity for fasting plasma glucose with receiver operator characteristic curves. RESULTS: For detection of the subcategory diabetes, a fasting plasma glucose of 89 mg/dl jointly maximizes sensitivity (88%) and specificity (78%), identifying 22% of the women as test-positive. For detection of impaired glucose tolerance, a value of 85 mg/dl jointly maximizes sensitivity and specificity (68%), identifying as test-positive 35% of the women. Lowering the cut point to 81 mg/dl increases sensitivity to 81%, but decreases specificity to 54%, labeling as test-positive 49% of the women. CONCLUSIONS: Fasting plasma glucose is a useful test for the screening of both subcategories of gestational diabetes, a threshold of 85 mg/dl being an acceptable option. Effective screening for the subcategory diabetes can be achieved using a cut point of 89 mg/dl. If greater emphasis is placed on the detection of impaired glucose tolerance, a lower value, 81 mg/dl, may be needed.

Waist circumference and waist-to-hip ratio are related to gestational glucose tolerance.

OBJECTIVE: To evaluate the relationship of central fat distribution with gestational glucose tolerance during the usual time for screening gestational diabetes. RESEARCH DESIGN AND METHODS: This cross-sectional study investigated 1,113 consecutive women, > or = 20 years old, pregnant for approximately 21 to 28 weeks, without history of previous diabetes outside pregnancy, who attended two general prenatal care units in Porto Alegre, Brazil, from 1991 to 1993. Weight, height, waist and hip circumferences, and skinfolds were measured, and a 2-h, 75-g glucose tolerance test was performed. Data were analyzed using multiple linear regression models. RESULTS: Waist-to-hip ratio (WHR) and waist circumference were independently associated with higher 2-h glycemia. Glycemic level was 0.11 and 0.13 mmol/l greater for each standard deviation increase in WHR (0.06) and waist circumference (8.0 cm), respectively (P < 0.02). Restricting analyses to the subset of women with uterine height < or = 26 cm improved the association (0.13 and 0.19 mmol/l, respectively, P < 0.02); differences of 0.22 and 0.19 mmol/l were observed for 1 SD changes in the sum of skinfold thicknesses (24.7 mm) and in age (5.5 years), respectively. CONCLUSIONS: Central fat distribution measured in pregnancy is an independent predictor of gestational glucose intolerance. This finding supports the concept that NIDDM and gestational diabetes are parts of the same disease, differing basically in their moment of detection. The usefulness of these anthropometric measurements in identifying pregnant women at high risk of having gestational glucose intolerance merits further investigation.

Variation in glucose tolerance with ambient temperature.

Ambient temperature may affect venous glucose concentration after glucose tolerance tests. We analysed 1030 standardised 75 g tests. Although mean fasting values did not differ, post-load values did: adjusted mean 2 h glucose concentration was 1.03 mmol/L lower at lower (5-14 degrees C) than at higher (25-31 degrees C) temperatures (p < 0.001). The occurrence of abnormal glucose tolerance doubled on warmer days. The diagnostic accuracy of the glucose tolerance test showed clinically significant temperature-associated variation. These variations, if confirmed, call for temperature standardisation during glucose tolerance testing and/or alternative strategies for use when standardisation is not feasible.

Effects of post-training beta-endorphin and Met-enkephalin administration on two-way active avoidance task in well-nourished and protein malnourished rats.

Protein malnutrition during suckling period or throughout the life affects the hypothalamic beta-endorphinergic system of adult rats. In the present study, rats were undernourished during suckling by feeding their dams an 8% casein diet whereas well-nourished dams received a 25% casein diet from birth until weaning (21 day of postnatal life). After weaning, the offsprings were maintained with the same diet as their dams. When rats were 3 month-old, they were subjected to two-way active avoidance task. Protein malnutrition did not affect the performance in the two-way active avoidance task. Post-training beta-endorphin or Met-enkephalin administration impaired the retention of shuttle avoidance task in both well-nourished and undernourished rats. However, the amnesic effect of the peptides was only achieved in undernourished rats with higher doses of opioids when compared to the well-nourished rats. These data suggest that undernourished rats present alterations in opioid sensitivity which may be related to changes in the levels of beta-endorphin previously observed both in brain and hypothalamus of early undernourished adult rats.

Effects of post-training beta-endorphin and Met-enkephalin administration on two-way active avoidance task in well-nourished and protein malnourished rats.

Protein malnutrition during suckling period or throughout the life affects the hypothalamic beta-endorphinergic system of adult rats. In the present study, rats were undernourished during suckling by feeding their dams an 8

casein diet whereas well-nourished dams received a 25

casein diet from birth until weaning (21 day of postnatal life). After weaning, the offsprings were maintained with the same diet as their dams. When rats were 3 month-old, they were subjected to two-way active avoidance task. Protein malnutrition did not affect the performance in the two-way active avoidance task. Post-training beta-endorphin or Met-enkephalin administration impaired the retention of shuttle avoidance task in both well-nourished and undernourished rats. However, the amnesic effect of the peptides was only achieved in undernourished rats with higher doses of opioids when compared to the well-nourished rats. These data suggest that undernourished rats present alterations in opioid sensitivity which may be related to changes in the levels of beta-endorphin previously observed both in brain and hypothalamus of early undernourished adult rats.

Effects of post-training beta-endorphin and Met-enkephalin administration on two-way active avoidance task in well-nourished and protein malnourished rats.

Protein malnutrition during suckling period or throughout the life affects the hypothalamic beta-endorphinergic system of adult rats. In the present study, rats were undernourished during suckling by feeding their dams an 8

casein diet whereas well-nourished dams received a 25

casein diet from birth until weaning (21 day of postnatal life). After weaning, the offsprings were maintained with the same diet as their dams. When rats were 3 month-old, they were subjected to two-way active avoidance task. Protein malnutrition did not affect the performance in the two-way active avoidance task. Post-training beta-endorphin or Met-enkephalin administration impaired the retention of shuttle avoidance task in both well-nourished and undernourished rats. However, the amnesic effect of the peptides was only achieved in undernourished rats with higher doses of opioids when compared to the well-nourished rats. These data suggest that undernourished rats present alterations in opioid sensitivity which may be related to changes in the levels of beta-endorphin previously observed both in brain and hypothalamus of early undernourished adult rats.