ABSTRACT Objective: Pregnancy complicated by type 2 diabetes is rising, while data on type 2 diabetes first diagnosed in pregnancy (overt diabetes) are scarce. We aimed to describe the frequency and characteristics of pregnant women with overt diabetes, compare them to those with known pregestational diabetes, and evaluate the potential predictors for the diagnosis of overt diabetes. Subjects and methods: A retrospective cohort study including all pregnant women with type 2 diabetes evaluated in two public hospitals in Porto Alegre, Brazil, from May 20, 2005, to June 30, 2021. Classic and obstetric factors associated with type 2 diabetes risk were compared between the two groups, using machine learning techniques and multivariable analysis with Poisson regression. Results: Overt diabetes occurred in 33% (95% confidence interval: 29%-37%) of 646 women. Characteristics of women with known or unknown type 2 diabetes were similar; excessive weight was the most common risk factor, affecting ~90% of women. Age >30 years and positive family history of diabetes were inversely related to a diagnosis of overt diabetes, while previous delivery of a macrosomic baby behaved as a risk factor in younger multiparous women; previous gestational diabetes and chronic hypertension were not relevant risk factors. Conclusion: Characteristics of women with overt diabetes are similar to those of women with pregestational diabetes. Classic risk factors for diabetes not included in current questionnaires can help identify women at risk of type 2 diabetes before they become pregnant.

ABSTRACT Objective Our objective was to evaluate gestational weight gain (GWG) patterns and their relation to birth weight. Subjects and methods We prospectively enrolled 474 women with gestational diabetes mellitus (GDM) at a university hospital (Porto Alegre, Brazil, November 2009-May 2015). GWG was categorized according to the 2009 Institute of Medicine guidelines; birth weight was classified as large (LGA) or small (SGA) for gestational age. Adjusted relative risks (aRRs) and 95% confidence intervals (95% CIs) were determined. Results Adequate GWG occurred in 121 women [25.5%, 95% CI: 22, 30%]; excessive, in 180 [38.0%, 95% CI: 34, 43%]; and insufficient, in 173 [36.5%, 95% CI: 32, 41%]. In women with normal body mass index (BMI), the prevalence of SGA was higher in those with insufficient compared to adequate GWG (30% vs. 0%, p < 0.001). In women with BMI ≥ 25 kg/m2, excessive GWG increased the prevalence of LGA [aRR 2.58, 95% CI: 1.06, 6.29] and protected from SGA [aRR 0.25, 95% CI: 0.10, 0.64]. Insufficient vs. adequate GWG did not influence the prevalence of SGA [aRR 0.61, 95% CI: 0.31, 1.22]; insufficient vs. excessive GWG protected from LGA [aRR 0.46, 95% CI: 0.23, 0.91]. Conclusions One quarter of this cohort achieved adequate GWG, indicating that specific ranges have to be tailored for GDM. To prevent inadequate birth weight, excessive GWG in women with higher BMI and less than recommended GWG in normal BMI women should be avoided; less than recommended GWG may be suitable for overweight and obese women.

RESUMO CONTEXTO E OBJETIVO: Prevalência e características do diabetes mellitus gestacional (DMG) modificaram-se com o tempo, refletindo transição nutricional e diferentes critérios diagnósticos. Nosso objetivo foi avaliar características de gestações com DMG em intervalo de 20 anos. TIPO DE ESTUDO E LOCAL: Comparação de duas coortes gestacionais arroladas em diferentes períodos, em hospitais universitários de Porto Alegre, Brasil: 1991 a 1993 (n = 216) e 2009 a 2013 (n = 375). MÉTODOS: Aplicamos dois critérios diagnósticos às coortes: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/Organização Mundial de Saúde (OMS); e National Institute for Health and Care Excellence (NICE). Comparamos características e desfechos materno-fetais entre as coortes e dentro de cada uma. RESULTADOS: Na coorte dos anos 2010, as mulheres eram mais velhas (31 ± 7 versus 30 ± 6 anos), obesas (29,4% versus 15,2%), apresentaram mais distúrbios hipertensivos (14,1% versus 5,6%) e risco aumentado de cesariana (risco relativo ajustado 1,8; intervalo de confiança de 95% 1,4 - 2,3), comparadas às da coorte de 1990. Desfechos neonatais, como categoria do peso ao nascer e hipoglicemia, foram semelhantes. Na coorte de 1990, essas características e desfechos foram semelhantes nas mulheres que preenchiam apenas um dos critérios; na de 2010, mulheres diagnosticadas apenas pelo IADPSG/OMS eram mais obesas (33 ± 8 kg/m2 versus 28 ± 6 kg/m2, P < 0,001) do que as diagnosticadas apenas pelo NICE. CONCLUSÃO: A epidemia de obesidade parece ter modificado o perfil de mulheres com DMG. Embora desfechos neonatais sejam semelhantes, houve diferenças na intensidade de tratamento ao longo do tempo. O critério da IADPSG/OMS parece identificar um perfil mais associado à obesidade.

ABSTRACT CONTEXT AND OBJECTIVE: The prevalence and characteristics of gestational diabetes mellitus (GDM) have changed over time, reflecting the nutritional transition and changes in diagnostic criteria. We aimed to evaluate characteristics of women with GDM over a 20-year interval. DESIGN AND SETTING: Comparison of two pregnancy cohorts enrolled in different periods, in university hospitals in Porto Alegre, Brazil: 1991 to 1993 (n = 216); and 2009 to 2013 (n = 375). METHODS: We applied two diagnostic criteria to the cohorts: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/World Health Organization (WHO); and National Institute for Health and Care Excellence (NICE). We compared maternal-fetal characteristics and outcomes between the cohorts and within each cohort. RESULTS: The women in the 2010s cohort were older (31 ± 7 versus 30 ± 6 years), more frequently obese (29.4% versus 15.2%), with more hypertensive disorders (14.1% versus 5.6%) and at increased risk of cesarean section (adjusted relative risk 1.8; 95% confidence interval: 1.4 - 2.3), compared with those in the 1990s cohort. Neonatal outcomes such as birth weight category and hypoglycemia were similar. In the 1990s cohort, women only fulfilling IADPSG/WHO or only fulfilling NICE criteria had similar characteristics and outcomes; in the 2010s cohort, women only diagnosed through IADPSG/WHO were more frequently obese than those diagnosed only through NICE (33 ± 8 kg/m2 versus 28 ± 6 kg/m2; P < 0.001). CONCLUSION: The epidemic of obesity seems to have modified the profile of women with GDM. Despite similar neonatal outcomes, there were differences in the intensity of treatment over time. The IADPSG/WHO criteria seemed to identify a profile more associated with obesity.

Objetivos: Os objetivos foram estimar a taxa de reavaliação de diabetes pós-parto em mulheres com diabetes melito gestacional (DMG) e identificar fatores associados ao retorno e à persistência das alterações glicêmicas. Sujeitos e métodos: Coorte prospectiva de mulheres com DMG atendidas em ambulatório de pré-natal especializado, de novembro de 2009 a maio de 2012. Todas foram orientadas a agendar o teste oral de tolerância à glicose (TOTG) a partir da sexta semana pós-parto. Resultados: Das 209 mulheres arroladas na gestação, 108 (51,7%) foram avaliadas após o parto: 14 com glicemia de jejum, 93 com o TOTG e uma com glicemia ao acaso. O retorno para reavaliação foi associado com menor paridade (2 vs. 3, p < 0,001) e com glicemia de 2-h mais elevada no TOTG diagnóstico (165 vs. 155 mg/dL, p = 0,034). Diabetes foi diagnosticado em quatro mulheres (3,7%) e pré-diabetes em 22 (20,4%). Análise multivariada evidenciou que a história familiar de diabetes (risco relativo – RR 2,41, p = 0,050), a glicemia de 2 horas no TOTG da gestação (RR 1,01, p = 0,045), o uso de insulina na gestação (RR 2,37, p = 0,014) e a taxa de cesariana (RR 2,61, p = 0,015) foram os fatores associados à persistência da hiperglicemia. Conclusões: O retorno para reavaliação foi baixo, embora as alterações glicêmicas tenham sido frequentes. Como não houve fatores que indiquem quais mulheres retornarão, estratégias para aumentar a adesão são necessárias, especialmente quando há história familiar ou o DMG foi mais grave. Arq Bras Endocrinol Metab. 2014;58(2):197-204

Objectives: The aims of this study were to estimate the local rate of postpartum diabetes screening after gestational diabetes mellitus (GDM) pregnancies, and to identify clinical variables associated with retesting rates and with the persistence of decreased glucose tolerance. Subjects and methods: Prospective cohort of GDM women with prenatal delivery at a specialized center, from November 2009 to May 2012. All women were advised to schedule a 6 weeks postpartum 75-g oral glucose tolerance test (OGTT). Results: Of the 209 women included, 108 (51.7%) returned to be tested with fasting plasma glucose (n = 14), OGTT (n = 93) or random glucose (n = 1). Return was associated with lower parity rate (2 vs. 3, p < 0.001) and higher pregnancy 2-h OGTT (165 vs. 155 mg/dL, p = 0.034), but not with socio-demographic characteristics. Four women (3.7%) had diabetes, 22 (20.4%) had impaired fasting glucose or impaired glucose tolerance. Persistent hyperglycemia was associated with a positive family history of diabetes (relative risk - RR 2.41, p = 0.050), diagnostic 2-h OGTT in pregnancy (RR 1.01, p = 0.045), insulin use during pregnancy (RR 2.37, p = 0.014), and cesarean section (RR 2.61, p = 0.015). Conclusions: Even though postpartum abnormalities were frequent in GDM, rates of postpartum diabetes screening were undesirably low. As no specific clinical profile defines who will adhere to postpartum testing, it is essential to encourage all women to reevaluate their glucose status, particularly those with a family history of diabetes and more severe hyperglycemia. Arq Bras Endocrinol Metab. 2014;58(2):197-204

O tratamento do diabetes gestacional é importante para evitar a morbimortalidade materno-fetal. O objetivo deste artigo é descrever o tratamento atualmente disponível para o manejo otimizado da hiperglicemia na gestação e sugerir um algoritmo de tratamento multidisciplinar. A terapia nutricional é a primeira opção de tratamento para as gestantes, e a prática de exercício físico leve a moderado deve ser estimulada na ausência de contraindicações obstétricas. O tratamento medicamentoso está recomendado quando os alvos glicêmicos não são atingidos ou na presença de crescimento fetal excessivo à ultrassonografia. O tratamento tradicional do diabetes gestacional é a insulinoterapia, embora mais recentemente a metformina venha sendo considerada uma opção segura e eficaz. A monitorização do tratamento é realizada com aferição da glicemia capilar e com avaliação da circunferência abdominal fetal por meio de ultrassonografia obstétrica a partir da 28ª semana de gestação.

Effective treatment of gestational diabetes is important as an attempt to avoid unfavorable maternal and fetal outcomes. The objective of this paper is to describe the available therapies to optimize gestational diabetes treatment and to suggest a multidisciplinary approach algorithm. Nutrition therapy is the first option for the majority of these pregnancies; light to moderate physical activity is recommended in the absence of obstetrical contraindications. Medical treatment is recommended if glycemic control is not achieved or if excessive fetal growth is detected by ultrasound. Insulin is the standard treatment although oral antidiabetic drugs have recently been considered an effective and safe option. The monitoring of gestational diabetes treatment includes capillary glucose measurements and evaluation of fetal abdominal circumference by ultrasound performed around the 28th gestational week.

OBJETIVOS: descrever, em gestantes do Estudo Brasileiro do Diabetes Gestacional (EBDG), a distribuição da altura uterina de acordo com a idade gestacional e validar a curva do Centro Latino-Americano de Perinatologia (CLAP), curva de referência para a predição de anormalidades do crescimento fetal. MÉTODOS: o EBDG é uma coorte de 5564 gestantes, com mais de 19 anos, seguidas até e após o parto. Entrevistas e medidas antropométricas padronizadas foram feitas no arrolamento entre a 20ª e a 28ª semana. Os prontuários foram revisados segundo protocolo padronizado, abrangendo os períodos de pré-natal e parto. As análises referem-se a 3539 gestantes com datação da gravidez confirmada por ultra-sonografia. Determinamos as propriedades diagnósticas dos percentis 10 e 90 de altura uterina de ambas as curvas (EBDG e CLAP) como indicadores de anormalidade no peso neonatal. RESULTADOS: as medidas de altura uterina no EBDG foram maiores que as do CLAP em todas as semanas de gestação (1 a 4 cm e 2 a 6 cm, respectivamente, nos percentis 10 e 90). O percentil 10 do CLAP identificou como pequenas as medidas uterinas de 0,3 a 1,7% das gestantes brasileiras, ao passo que o percentil 90 classificou como grandes as medidas uterinas de 42 a 57% das brasileiras. A sensibilidade do percentil 10 do CLAP para predizer recém-nascidos pequenos para a idade gestacional variou de 0,8 a 6% e a especificidade do percentil 90 para predizer grandes para a idade gestacional, de 46 a 61%. CONCLUSÕES: a curva de referência do CLAP não reflete o padrão de crescimento uterino das gestantes brasileiras, limitando sua capacidade de identificar anormalidades de crescimento fetal, especialmente a restrição de crescimento.

PURPOSE: to describe, in participants of the Brazilian Study of Gestational Diabetes (EBDG), the percentile distribution of uterine height by gestational age and to validate the use of percentiles of the chart derived by the "Centro Latino-Americano de Perinatologia" (CLAP), used as reference in predicting abnormal fetal growth. METHODS: the EBDG is a cohort study of 5564 pregnant women older than 19 years, followed through and after delivery. Interviews and standardized anthropometry were performed at baseline between 20-28 weeks. Medical records covering prenatal and delivery periods were then reviewed following a standardized approach. Analyses pertain to 3539 women with gestational age confirmed by ultrasound. Diagnostic properties of the 10th and the 90th percentiles of both charts (EBDG and CLAP) as predictors of abnormal neonatal weight were determined. RESULTS: uterine height was higher in EBDG than in the CLAP chart at every gestational week, being 1-4 and 2-6 cm greater, at the 10th and 90th percentiles respectively. The CLAP 10th percentile classified as small the uterine heights of only 0.3 to 1.7% of Brazilian women, while the 90th percentile classified as large the uterine heights of 42 to 57% of the sample. The sensitivity of CLAP percentile 10 in the prediction of small for gestational age varied from 0.8 to 6% and the specificity of CLAP percentile 90 in the prediction of large for gestational age, from 46 to 61%. CONCLUSIONS: the CLAP uterine height reference chart does not reflect the current uterine growth pattern of pregnant Brazilians, limiting its clinical applicability in the detection of abnormal fetal growth, especially intrauterine growth restriction.

O Grupo de Trabalho em Diabetes e Gravidez, reunido durante o XI Congresso Brasileiro de Diabetes em 1997, elaborou normas para o manejo do diabetes gestacional e pré-gestacional. Em 2001, nova reunião ocorreu visando atualizar os posicionamentos assumidos em 1997, a partir de novas evidências da literatura. As mudanças sugeridas estão incorporadas no documento a seguir. O rastreamento do diabetes gestacional deve ser universal e, para isso, é sugerido o emprego da glicemia de jejum a partir da 20ª semana de gestação. Os pontos de corte para classificação de rastreamento positivo são 85mg/dl ou 90mg/dl; nos casos de rastreamento positivo, o exame recomendado é o teste oral de tolerância com 75g de glicose e os critérios para o diagnóstico do diabetes gestacional são glicemia de jejum > ou = 110mg/dl ou glicemia de 2h > ou = 140mg/dl. São apresentadas também estratégias de manejo metabólico e obstétrico do diabetes gestacional e do diabetes pré-gestacional.

Clinical guidelines for the management of gestational and pre-gestational diabetes were prepared by the Diabetes and Pregnancy Task Force, during the XI Brazilian Diabetes Congress, held in 1997. A new meeting was held in 2001 to revise recommendations for screening, diagnosis and management of gestational diabetes, based on the new evidences generated on these issues. Universal screening of pregnant women is advised beginning at the 20th week of gestation, using fasting plasma glucose. Cut points of 85mg/dl or 90mg/dl are used to classify a positive screening. A 75g oral glucose tolerance test is performed if the screening test is positive. The diagnostic cut points suggested to define glucose alterations are a fasting plasma glucose <FONT FACE=Symbol>³</FONT>110mg/dl or a 2h plasma glucose <FONT FACE=Symbol>³</FONT>140mg/dl. Endocrine and obstetric management of gestational diabetes as well as a review on pre-gestational diabetes management are also presented.