Portuguese versus Fenton Curve: Which one better explains maternal and neonatal outcomes in Portuguese women with gestational diabetes?

BACKGROUND AND AIMS: Growth charts are commonly used to identify foetal growth alterations, playing an important role as extreme growth centiles correlate with worse foetal and neonatal outcomes. This study aim was to compare birthweight classification (small for gestational age (SGA), adequate for gestational age and large for gestational age (LGA)) from women with gestational diabetes mellitus (GDM) by applying the population-based growth chart (Fenton Curve) and the standard chart customised for our country (Portuguese Curve). Moreover, we compared obstetric and neonatal outcomes according to birthweight classification between these curves. METHODS: A multicentre observational study with prospectively collected data from 19,470 pregnant women diagnosed with GDM (30 Portuguese institutions) was conducted. RESULTS: The proportion of SGA neonates was higher with Fenton Chart than with Portuguese standard chart (12.7% vs 10.9%) and the prevalence of LGA was higher using the Portuguese Chart (4.1%vs 10.9%). Statistically significant differences in the classifications given by the two curves and for maternal/neonatal outcomes were found. The Area Under the Curve and Akaike Information Criterion pointed out to a better correlation between weight classification of the Portuguese Curves and the majority of expected maternal and neonatal outcomes: gestational hypertension, preeclampsia, hydramnios, vaginal dystocic labour, hyperbilirubinemia, respiratory distress syndrome, trauma from delivery, admission in neonatal intensive care unit, prematurity and neonatal morbidity. CONCLUSION: Our study highlights the importance of having a standard birthweight curve specifically designed for each population. Neonates' weight classification carries prognostic implication and misclassification could lead to potential mistreatment or overtreatment.

HbA1c as a predictor of postpartum diabetes mellitus after gestational diabetes mellitus.

AIMS: Women diagnosed with Gestational Diabetes Mellitus (GDM) should be evaluated postpartum with an Oral Glucose Tolerance Test (OGTT). Nevertheless, women frequently fail to it. We intend to evaluate the performance of third trimester HbA1c in the prediction of postpartum diabetes mellitus (PDM). METHODS: We conducted a retrospective study of 10245 women with GDM based on the National Registry of GDM. A receiver-operating characteristic (ROC) curve was plotted to evaluate the diagnostic performance of third trimester HbA1c in PDM prediction. RESULTS: The mean third trimester HbA1c level was 5.81% (SD 0.69%) in women who developed PDM, 5.40% (SD 0.52%) in women with pre-diabetes and 5.21% (SD 0.43%) in women with normal glucose tolerance in postpartum OGTT, with statistically significant differences (p < 0.0001). As to the ROC curve ability to predict PDM was fair, with an optimal cut-off point of HbA1c of 5.4%. Women presenting HbA1c values ≥ 5.4% were 6.1 times more likely to develop PDM. CONCLUSIONS: A third trimester HbA1c level ≥5.4% is associated with a significant higher risk of PDM (p < 0.0001). It could be used as a reliable tool for screening women with GDM and detect who will benefit the most from a close follow-up after pregnancy.

Intensive calcium monitoring improves outcomes on hungry bone syndrome in hyperparathyroidism.

Objectives. Hungry bone syndrome (HBS) is a severe and underdiagnosed complication of parathyroidectomy in the treatment of primary hyperparathyroidism (PHP) and secondary hyper-parathyroidism to chronic kidney disease (SHP-CKD).Methods. A longitudinal study was conducted to compare the postoperative outcomes of patients who developed HBS in two different time frames: before and after implementing a protocol with an intensive electrolytic monitoring and an algorithm regarding electrolytic supplementation.Results. Overall, 77 parathyroidectomies were included. In PHP, a protocol implementation led to an increased admission of patients in the Intermediate Care Unit for intensive electrolytic monitoring (p<0.001) and an increased rate of oral calcium replacement during hospital stay (p=0.013) compared to pre-protocol era. In SHP-CKD, duration of intravenous calcium replacement was reduced (p=0.010). The prevalence of HBS (9.8% in PHP and 58.3% in SHP-CKD) was similar between the two periods, although its diagnosis had an increased trend in PHP since the protocol implementation. None of the diagnosis of HBS was established due to hypocalcemic symptoms in the post-protocol era (contrary to pre-protocol period, p=0.021). Both hypocalcemia length and duration of surgical ward hospitalization were reduced (p=0.047 and p=0.042, respectively).Conclusions. An improved assessment of hyperparathyroidism and a decrease in HBS severity were noted in the post-protocol era. We strongly recommend the implementation of a standardized protocol with an intensive phosphocalcium monitoring in the high-risk patients who undergo parathyroidectomy due to hyperparathyroidism as it improves the health care and management of HBS.

Controversial Screening for Thyroid Dysfunction in Preconception and Pregnancy: An Evidence-Based Review.

Objective: To evaluate the recommendations on the most adequate screening method (universal or selective) for thyroid dysfunction. Although thyroid dysfunction is a common disorder in fertile women and untreated cases may have negative maternal, fetal and neonatal outcomes, its screening in preconception and early pregnancy is controversial. Materials and methods: An evidence-based review was conducted to identify publications since 2017 of American Thyroid Association (ATA) guidelines, according to the following Population, Intervention, Comparison, Outcomes and Study (PICOS): women in preconception or pregnancy without thyroid disease who underwent universal or selective screening for thyroid dysfunction. Study selection obeyed the PRISMA criteria. Results: We included 15 of 325 publications. The 2017 ATA guidelines recommend selective screening in both preconception and pregnancy. The only two reviews on preconception recommended universal screening. For pregnancy, nine articles suggested universal screening, while a prospective study advocated selective screening. The main benefits advocated for universal screening were easy and low-cost tests; absence of missed diagnosis; safe and inexpensive treatment and its potential in preventing negative outcomes. Iodine deficiency is a decisive indication, but it was not evaluated in all clinical studies. Screening harms and knowledge gaps were the main arguments against universal screening. There are very few cost-effectiveness studies. Conclusion: We recommend universal screening for thyroid dysfunction in early pregnancy, which is a distinct point of view from 2017 ATA guidelines (weak recommendation, low-quality evidence). It is not possible to make a formal recommendation for preconception (insufficient evidence). We strongly suggest an individualized analysis by each country.

Pharmacologic Therapies in Anticoagulation.

Anticoagulants are beneficial for prevention and treatment of venous thromboembolism and stroke prevention in atrial fibrillation. The development of target-specific oral anticoagulants is changing the landscape of anticoagulation therapy and created growing interest on this subject. Understanding the pharmacology of different anticoagulants is the first step to adequately treat patients with best available therapy while avoiding serious bleeding complications. This article reviews the pharmacology of the main anticoagulant classes (vitamin K antagonists, direct oral anticoagulants, and heparins) and their clinical indications based on evidence-based data currently available in the literature.