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Culture Documents
Uptodate 2015
Diabetes Mellitus
Es
una
enfermedad
metablica
endocrinolgica
crnica
caracterizada por el dficit relativo o absoluto de insulina
(Alteraciones en la secrecin, o accin de la insulina) resultando
en hiperglicemia perdida de la homeostasis de la glucosa
Causas: (Multifactorial, gentica, inmunolgica, adquirida)
Deficiencia de insulina
Resistencia a la insulina
Impacto de la Hiperglicemia:
Riesgos para la madre y su feto
Disfuncin multi orgnica
Mortalidad elevada
Manifestaciones:
Intolerancia a la glucosa
Cetoacidosis
Complicaciones crnicas
2
Diabetes en la Gestacin
Epidemiologia
4 - 6% de los embarazos en USA se complican con DM,
representan 50 - 150,000 / ao. 30 35% recurrencia
88% GDM, el 8% DM tipo II, el 4% DM tipo 1
Epidemia actual: Obesidad y diabetes: ms casos de diabetes tipo
2 en las MEF y ms casos de mujeres embarazadas con diabetes
tipo 2 no diagnosticada
Complicacin mdica ms comn de la gestacin
DM Gestacional
DM Preexistente
90%
10%
El
estudio
epidemiolgico
multinacional
HAPO
(Hyperglucemia and Pregnancy Outcome Adverse, 25.000
mujeres embarazadas), demostr que el riesgo de los
resultados maternos, fetales y neonatales adversos aument
continuamente en funcin de la glucemia materna desde las
24 - 28 semanas
Este nuevo enfoque aument la prevalencia de DMG ya que
basta un solo valor anormal para hacer su diagnstico (de 4
al 6%)
GDM es ms comn entre las personas de ascendencia
asitica o etnia hispana y menos comn en personas de
ascendencia europea; e incidencia intermedia en las
mujeres afroamericanas
HAPO
Embarazo
normal:
Hipoglucemia en
ayunas leve
Hiperglucemia
postprandial
Hiperinsulinemia
Debido a la resistencia
perifrica a la insulina
lo que asegura un
suministro adecuado de
glucosa para el beb
11
de la concentracin de FFA
Fisiopatologa
La DMG es causada por una reduccin (en la primera fase) en
la funcin de las clulas del pancreas que lleva a una
disfuncin de ellas
Las alteraciones en la sensibilidad a la insulina llevan a
alteraciones del metabolismo de las grasas, carbohidratos,
aminocidos etc.
Ms evidente entre las 26 y 30 semanas
Insulinasa: Producto placentario que puede jugar un rol <
Potencia Diabetgena y mxima secrecin: (1: dbil, 5: fuerte)
Estradiol
1
26 semanas
Prolactina
2
10 semanas
hPL
3
26 semanas
Cortisol
5
26 semanas
Progesterona
4
32 semanas
14
Crculo Vicioso?
15
16
17
18
19
20
21
Cambios Patolgicos en la DG
Deficiencia de
Insulina
Resistencia a la
Insulina
22
Hiperglicemia
fetal
Trauma
del
nacimiento:
complicaciones relacionadas
distocia
de
hombro
las
24
de almacenamiento de
oxgeno fetal e hipoxia fetal
episdica
Hipertensin fetal
Remodelacin cardaca y la
hipertrofia
El de la eritropoyetina,
glbulos rojos, hematocrito
La mala circulacin fetal e
hiperbilirrubinemia
26
28
29
30
31
32
33
Clasificacin
1.
2.
3.
la
gestacin.
34
35
Clase
Inicio
A1
Gestacional
A2
Gestacional
Clase
Glucosa
Plasmtica
en ayunas
Glucosa 2 hr Post
Prandial
Terapia
Edad de
inicio
Duracin
Enfermedad Vascular
Terapia
> 20
< 10
No
insulina
10 a 19
10 a 19
No
insulina
< 10
> 20
Retinopata Benigna
insulina
Cualquiera
Cualquiera
Nefropata
insulina
Cualquiera
Cualquiera
Retinopata Proliferativa
insulina
Cualquiera
Cualquiera
Corazn
insulina
<120 mg/dl
Dieta y
Insulina
36
Recomendaciones
Hacer screening en la primera visita prenatal en pacientes con factores
de riesgo usando los criterios de Dx estndar para D/C DM Tipo 2 (B)
En las mujeres embarazadas que no saben que tienen diabetes, hacer
screening a las 24 - 28 semanas, con 75 g de glucosa TTOG 2 h y hacer el
diagnstico de acuerdo a los puntos de corte (B)
Screening a mujeres con GDM con diabetes persistente en 6 - 12 semanas
post parto, utilizando el TTOG y el Dx de acuerdo criterios de Dx de las
embarazadas (E)
Mujeres con antecedentes de DMG deben hacerse una revisin a lo largo
de toda su vida para Dx diabetes o prediabetes al menos c/3 aos (B)
37
Puntos Clave
La DMG esta asociada con un modesto incremento en los resultados
adversos perinatales, un incremento de riesgo de obesidad en sus hijos y
un alto riesgo de desarrollar subsecuentemente Diabetes Mellitus en la
madre
La DMG es tratada con dieta, es decir nutricionalmente, insulina or
antidiabticos orales pueden ser agregados si los niveles de glucosa
maternos y/o parmetros de crecimiento fetal indican un suficiente alto
riesgo de complicaciones perinatales
Manejo a largo plazo de las madres incluye la evaluacin del nivel y tipo de
diabetes y de evaluacin de nuesvos estilos de vida y agentes
farmacolgicos para mujeres con tipo II de diabetes
Manejo a largo plazo de sus hijos debera enfocar la deteccin y mitigacin
del desarrollo de la obesidad y de sus complicaciones
38
39
40
41
42
43
Infeccin materna
Cetoacidosis diabtica
Mal control o no cumplimiento
Labor pretermino
45
Diagnstico
Dos glicemias ayuno > 105 mg/dl
TTGO 75gr > 140 mg/dl a las 2 horas
Cualquier glicemia mayor a 200 mg/dl
Triaje: Primer control Embarazo de glicemia en ayuno
TTGO 75 gr entre 24 - 28 semanas y repetir
entre 32 - 34 semanas
46
Diabetes Gestational
Manejo:
Objetivo: optimizar los niveles de glucosa sangunea
para minimizar los resultados adversos neonatales
Dieta: tiene lugar
Autocontrol Domiciliario
Ejercicios
Antidiabticos orales
Terapia Insulnica
47
Diabetes Gestational
Manejo: Dieta
Evitar la cetosis
Programa de ejercicio liberal para optimizar el control
de la glucosa sangunea
48
Diabetes Gestational
Si la hiperglicemia persiste despus de 1 semana de control
diettico: proceder a usar Insulina
06
14
26
36
- 14 semanas
- 26 semanas
- 36 semanas
40 semanas
0.5
0.7
0.9
1
u
u
u
u
/
/
/
/
kg
kg
kg
kg
/
/
/
/
day
day
day
day
49
Control Glicemia
Glicemia de ayunas: Menor de 105
Glicemia Post prandial: Menor de 120
Insulina: 0.3 - 0.5 u / kg
Insulina repartir 2/3 diurnos y 1/3 nocturnos
Insulina NPH: 0.1 - 0.3 u / kg
Insulina Cristalina 2 a 4 U. Pre almuerzo y comida
Lo ms frecuente: mezcla de NPH y Cristalina dos dosis diarias
90 % se controlan con Dieta
Dieta de la ADA
1800 caloras
2200 caloras
2400 caloras
51
Cebada
33
Legumbres / Frejoles
30
Panes multigranos
40
Copos de avena
50
60
Leche descremada
34
Yogurt
Alto
30 - 40
50
Papas
85
Copos de maz
77
Arroz inflado
85
Pan Integral
70
Galletas
81
Arroz
83
52
Foster-Powell K, Holt SHA, and Brand-Miller JC. International table of glycemic index and glycemic load
values:2002. Am J Clin Nutr. 2002; 76 (1): 5-56.
Control Obsttrico
Normal hasta las 28 semanas, luego cada 15 das hasta las
34 semanas y semanal hasta el parto
Altura uterina, EPF, Volumen LA, Control PA
Cetonuria (cetosis de ayuno)
Urocultivo primer trimestre y 28 semanas
Condicin Fetal desde 34 semanas
53
8 - 10 semanas
16 semanas
20 - 22
semanas
24 semanas
28 semanas
32 semanas
34 semanas
36 semanas
37 - 38.5
semanas
38.5 - 40
semanas
Antidiabticos orales en la DG
Contraindicados
Sulfonilureas de Primera Generacin: atraviesan la placenta
55
Metformina
Disminuye
infantil
incidencia
Cuidados Anteparto de la DG
Asesoramiento diettico
Monitorizacin de la glucosa (5 veces por da)
Terapia de insulina si es necesario (Agentes Hipoglucemiantes
orales)
Frecuente control de la glucosa
57
Manejo Intraparto
Requisitos absolutos:
Dextrosa contenida en lquidos por va intravenosa
Insulina
Control de la glucosa por hora
Monitoreo Continuo de la frecuencia cardaca fetal
Tocodinanometra continua
Manejo de la labor en forma normal. Va ms disponible
58
Fetal
Indicacin
NST no reactivo + CST Reactivo
Madurez fetal ms evidencia sonogrfica de
arresto en el crecimiento fetal
Disminucin del crecimiento fetal, disminucin
del lquido amnitico y 40 - 41 semanas
Materna
Preeclampsia Severa
Preeclampsia leve , feto maduro
Falla renal marcada
Obsttrica
59
metablica
37
38
semanas
60
Cesrea electiva
A primera hora y suspender Insulina matinal
Dextrosa 5% a 125 cc / hr
62
Anticoncepcin
Acido Flico: 0.4 mg. ARO: 4 mg/d )disminuir riesgo de Defectos
del Tubo Neural)
Aumento del riesgo de la obesidad y de tolerancia anormal a la
glucosa
17 - 63 % de riesgo de hacer diabetes no gestacional dentro de 5
a 16 aos despus de la DG, segn los factores de riesgo
63
64
65
66
67
68
69
70
Diabet
Med.
2011
Aug;28(8):900-5.
doi:
10.1111/j.14645491.2011.03291.x. A meta - analysis of the association between preeclampsia and childhood-onset Type 1 diabetes mellitus. Henry
EB, Patterson CC, Cardwell CR.
Data were available from 16 studies including 8315 children with Type
1 diabetes
This association did not vary much between studies (I(2) = 28%, P for
heterogeneity =0.14). The association was similar in three cohort
studies (OR = 1.05, 95% CI 0.77-1.44; P = 0.75) and in seven studies with
a low risk of bias (OR = 1.13, 95% CI 0.91-1.40; P = 0.27), but was more
marked in 13 studies which ascertained pre-eclampsia from obstetrical
records or birth registry data (OR = 1.18, 95% CI 1.03-1.36; P = 0.02)
71
Conclusions
This analysis demonstrates little evidence of any substantial
increase in childhood Type 1 diabetes risk after pregnancy
complicated by pre - eclampsia
72
73
Conclusions
This analysis demonstrates a 20% increase in the risk of childhoodonset type 1 diabetes after Caesarean section delivery that cannot
be explained by known confounders
74
NICE clinical guidelines Issued: March 2008 (last modified: July 2008) CG63
Diabetes in pregnancy: Management of diabetes and its complications from
pre - conception to the postnatal period
Diabetes is a disorder of carbohydrate metabolism that requires immediate
changes in lifestyle
75
diabetic
retinopathy
can
worsen
rapidly
during
76
Cochrane
Database
Syst
Rev.
2008
Apr
16;(2):CD006674.
doi:
10.1002/14651858.CD006674.pub2.. Dietary advice in pregnancy for preventing
gestational diabetes mellitus. Tieu J, Crowther CA, Middleton P.
Gestational diabetes mellitus (GDM) is a form of diabetes that occurs
during pregnancy which can result in significant adverse outcomes for mother
and child both in the short and long term. The potential for adverse outcomes, in
addition to the increasing prevalence of gestational diabetes worldwide,
demonstrates the need to assess strategies, such as dietary advice, that might
prevent gestational diabetes.
Three trials (107 women) were included in the review. One trial (25 pregnant
women) analysed high - fibre diets with no included outcomes showing
statistically significant differences. Two trials (82 pregnant women) assessed low
glycaemic index (LGI) versus high glycaemic index diets for pregnant women.
Women on the LGI diet had fewer large for gestational age infants (one trial;
relative risk (RR) 0.09, 95% confidence interval (CI) 0.01 to 0.69), infants with
lower ponderal indexes (two trials; weighted mean difference (WMD) -0.18, 95%
CI -0.32 to -0.04, random-effects analysis) and lower maternal fasting glucose
levels (two trials; WMD -0.28 mmol/L 95% CI -0.54 to -0.02, random-effects model).
Results for women on the LGI diet on neonatal birth weight were not conclusive
under a random-effects model (two trials; WMD -527.64 g, 95% CI -1119.20 to
63.92); however, on a fixed-effect model, women on the LGI diet gave birth to
lighter babies (two trials; WMD -445.55 g, 95% CI -634.16 to -256.95). High
heterogeneity was observed between the trials in most results and both were
relatively small trials. One of these trials also included a standard exercise
regimen for all participants.
77
Conclusions
78
BMC Public Health. 2011 Apr 13;11 Suppl 3:S2. doi: 10.1186/1471-2458-11S3-S2. Effect of screening and management of diabetes during pregnancy on
stillbirths. Syed M, Javed H, Yakoob MY, Bhutta ZA.
A total of 70 studies were selected for data extraction including fourteen intervention
studies and fifty six observational studies. No randomized controlled trials were
identified evaluating early detection of diabetes mellitus in pregnancy versus standard
screening (glucose challenge test between 24th to 28th week of gestation)
in pregnancy.
Intensive management of gestational diabetes (including specialized dietary advice,
increased monitoring and tailored dietary therapy) during pregnancy (3 studies: 3791
participants) versus conventional management (dietary advice and insulin as required)
was associated with a non-significant reduction in the risk of stillbirths (RR 0.20; 95%
CI: 0.03-1.10) ('moderate' quality evidence)
Optimal control of serum blood glucose versus sub-optimal control was associated
with a significant reduction in the risk of perinatal mortality (2 studies, 5286
participants: RR = 0.40, 95% CI 0.25- 0.63), but not stillbirths (3 studies, 2469
participants: RR = 0.51, 95% CI 0.14-1.88). Preconception care of diabetes (information
about need for optimization of glycemic control before pregnancy, assessment
of diabetes complications, review of dietary habits, intensification of capillary blood
glucose self-monitoring and optimization of insulin therapy) versus none (3 studies: 910
participants) was associated with a reduction in perinatal mortality (RR = 0.29, 95% CI
0.14
-0.60).
Using
the
Delphi
process
for
estimating
effect
size
of
optimal diabetes recognition and management yielded a median effect size of 10%
reduction in stillbirths
79
Conclusions
Diabetes, especially pre-gestational diabetes with its attendant
vascular complications, is a significant risk factor for stillbirth and
perinatal death
Our review highlights the fact that very few studies of adequate
quality are available that can provide estimates of the effect of
screening for aid management of diabetes in pregnancy on stillbirth
risk
Using the Delphi process we recommend a conservative 10%
reduction in the risk of stillbirths, as a point estimate for inclusion
in the LiST.
80
Conclusions
Treatment for gestational diabetes, consisting of treatment to
lower blood glucose concentration alone or with special
obstetric care, seems to lower the risk for some perinatal
complications
Decisions regarding treatment should take into account that the
evidence of benefit is derived from trials for which women were
selected with a two step strategy (glucose challenge
test/screening for risk factors and oral glucose tolerance test)
82
Cochrane
Database
Syst
Rev.
2012
Jul
10.1002/14651858.CD009021.pub2.
Exercise
for
pregnant
gestational diabetes mellitus. Han S, Middleton P, Crowther CA.
11;7:CD009021.
doi:
women
for
preventing
We included five trials with a total of 1115 women and their babies (922 women and their
babies contributed outcome data). Four of the five included trials had small sample sizes
with one large trial that recruited 855 women and babies. All five included trials had a
moderate risk of bias. When comparing women receiving additional exercise interventions
with those having routine antenatal care, there was no significant difference in GDM
incidence (three trials, 826 women, risk ratio (RR) 1.10, 95% confidence interval (CI) 0.66 to
1.84), caesarean section (two trials, 934 women, RR 1.33, 95% CI 0.97 to 1.84) or operative
vaginal birth (two trials, 934 women, RR 0.83, 95% CI 0.58 to 1.17)
No trial reported the infant primary outcomes prespecified in the review. None of the five
included trials found significant differences in insulin sensitivity. Evidence from one single
large
trial
suggested
no
significant
difference
in
the
incidence
of
developing pregnancy hyperglycaemia not meeting GDM diagnostic criteria, pre-eclampsia or
admission to neonatal ward between the two study groups
Babies born to women receiving exercise interventions had a non-significant trend to a lower
ponderal index (mean difference (MD) -0.08 gram x 100 m(3), 95% CI -0.18 to 0.02, one trial,
84 infants)
No significant differences were seen between the two study groups for the outcomes of birth
weight (two trials, 167 infants, MD -102.87 grams, 95% CI -235.34 to 29.60), macrosomia (two
trials, 934 infants, RR 0.91, 95% CI 0.68 to 1.22), or small-for-gestational age (one trial, 84
infants, RR 1.05, 95% CI 0.25 to 4.40) or gestational age at birth (two trials, 167 infants, MD 0.04 weeks, 95% CI -0.37 to 0.29) or Apgar score less than seven at five minutes (two trials,
919 infants, RR 1.00, 95% CI 0.27 to 3.65).
None of the trials reported long-term outcomes for women and their babies
No information was available on health services costs.
83
Conclusions
There is limited randomised controlled trial evidence available on the
effect of exercise during pregnancy for preventing pregnancy glucose
intolerance or GDM
Results from three randomised trials with moderate risk of bias
suggested no significant difference in GDM incidence between women
receiving an additional exercise intervention and routine care
84
J
Womens
Health
(Larchmt).
2011
Oct;20(10):1551-63.
doi:
10.1089/jwh.2010.2703. Epub 2011 Aug 12. Interventions for preventing
gestational diabetes mellitus: a systematic review and meta - analysis.
Oostdam N, van Poppel MN, Wouters MG, van Mechelen W.
Nineteen studies evaluating six types of interventions were included.
Dietary counseling significantly reduced GDM incidence compared to
standard care
85
Conclusions
The results indicate that there may be some benefits of dietary
counseling, an LGI diet advice, or an exercise program
However, better-designed studies are required to generate higher
quality evidence
At the moment, no strong conclusions can be drawn with regard to
the best intervention for prevention of GDM
86
87
Conclusion
Women with a history of preeclampsia have an increased risk of
microalbuminuria with a prevalence similar to the published
prevalence in patients with type 1 diabetes mellitus
Further research is needed to determine whether the increased risk
of microalbuminuria persists after adjustment for a thorough set of
confounding factors in larger populations and the mechanisms
underlying this association
88
89
Conclusion
There is a slightly higher risk of major congenital malformations
in women with gestational diabetes than in the reference group
The contribution of women with overt hyperglycemia and other
factors could not be ascertained
This risk, however, is
pregestational diabetes
much
lower
than
in
women
with
90
J Clin Endocrinol Metab. 2009 Nov;94(11):4284-91. doi: 10.1210/jc.20091231. Epub 2009 Oct 6. Maternal and fetal outcome in women with type
2 versus type 1 diabetes mellitus: a systematic review and
metaanalysis. Balsells M, Garca-Patterson A, Gich I, Corcoy R.
Thirty-three studies qualified for inclusion of 3743 citations retrieved
Women with type 2 DM had lower glycated hemoglobin (HbA1c) at
booking and throughout pregnancy but a higher risk of perinatal
mortality [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.15-1.96]
without significant differences in the rates of major congenital
malformations, stillbirth, and neonatal mortality
As to secondary outcomes, women with type 2 DM had less diabetic
ketoacidosis (OR 0.09, 95% CI 0.02-0.34) and cesarean section (OR
0.80, 95% CI 0.59-0.94) without differences in other outcomes
92
Conclusions
Despite a milder glycemic disturbance, women with type 2 DM had
no better perinatal outcomes than those with type 1, indicating that
type 2 DM in pregnancy is a serious condition
93
Am
J
Obstet
Gynecol.
2010
Nov;203(5):457.e1-9.
doi:
10.1016/j.ajog.2010.06.044. Epub 2010 Aug 24. Oral hypoglycemic
agents vs insulin in management of gestational diabetes: a systematic
review and metaanalysis. Dhulkotia JS, Ola B, Fraser R, Farrell T.
Six studies comprising 1388 subjects were analyzed
No significant differences were found in maternal fasting (weighted
mean difference [WMD], 1.31; 95% confidence interval [CI], 0.81-3.43) or
postprandial (WMD, 0.80; 95% CI, -3.26 to 4.87) glycemic control
Use of oral hypoglycemic agents (OHAs) was not associated with risk of
neonatal hypoglycemia (odds ratio [OR], 1.59; 95% CI, 0.70-3.62),
increased birthweight (WMD, 56.11; 95% CI, -42.62 to 154.84), incidence
of caesarean section (OR, 0.91; 95% CI, -0.68 to 1.22), or incidence of
large-for-gestational-age babies (OR, 1.01; 95% CI, 0.61-1.68).
94
Conclusion
95
96
Conclusions
Higher levels of physical activity before pregnancy or in
early pregnancy are associated with a significantly lower risk of
developing GDM
97
BMC Pregnancy Childbirth. 2010 Oct 14;10:63. doi: 10.1186/1471-239310-63. Preconception care for diabetic women for improving maternal
and fetal outcomes: a systematic review and meta-analysis. Wahabi
HA, Alzeidan RA, Bawazeer GA, Alansari LA, Esmaeil SA.
Meta - analysis suggested that preconception care is effective in
reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17
(95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8
(95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT =
32 (95% CI 19-109)
Preconception care lowers HbA1c in the first trimester of pregnancy by
an average of 2.43% (95% CI 2.27-2.58)
98
Conclusion
Preconception care is effective in reducing diabetes related
congenital
malformations,
preterm
delivery
and
maternal
hyperglycemia in the first trimester of pregnancy
99
BMC Pregnancy Childbirth. 2009 May 7;9 Suppl 1:S5. doi: 10.1186/1471-23939-S1-S5.
Reducing
stillbirths:
screening
and
monitoring
during pregnancy and labour. Haws RA, Yakoob MY, Soomro T, Menezes
EV, Darmstadt GL, Bhutta ZA.
We found a dearth of rigorous evidence of direct impact of any of these
screening procedures and interventions on stillbirth incidence
Observational studies testing some interventions, including fetal movement
monitoring and Doppler monitoring, showed some evidence of impact on
stillbirths in selected high-risk populations, but require larger rigourous
trials to confirm impact
Other interventions, such as amniotic fluid assessment for oligohydramnios,
appear predictive of stillbirth risk, but studies are lacking which assess the
impact on perinatal mortality of subsequent intervention based on test
findings
Conclusion
There are numerous research gaps and large, adequately controlled
trials are still needed for most of the interventions we considered
The impact of monitoring interventions on stillbirth relies on use of
effective and timely intervention should problems be detected.
Numerous studies indicated that positive tests were associated with
increased perinatal mortality, but while some tests had good sensitivity
in detecting distress, false-positive rates were high for most tests, and
questions remain about optimal timing, frequency, and implications of
testing
Cochrane
Database
Syst
Rev.
2009
Jul
8;(3):CD003395.
doi:
10.1002/14651858.CD003395.pub2. Treatments for gestational diabetes. Alwan
N, Tuffnell DJ, West J.
Eight randomised controlled trials (1418 women) were included.
Caesarean section rate was not significantly different when comparing any
specific treatment with routine antenatal care (ANC) including data from five
trials with 1255 participants (risk ratio (RR) 0.94, 95% confidence interval (CI)
0.80 to 1.12).
However, when comparing oral hypoglycaemics with insulin as treatment for
GDM, there was a significant reduction (RR 0.46, 95% CI 0.27 to 0.77, two trials,
90 participants).
103
104
Conclusions
Specific treatment including dietary advice and insulin for mild GDM
reduces the risk of maternal and perinatal morbidity
However, it is associated with higher risk of labour induction
More research is needed to assess the impact of different types of
intensive treatment, including oral drugs and insulin, on individual
short - and long-term infant outcomes.
105
Lancet.
2009
May
23;373(9677):1773-9.
doi:
10.1016/S01406736(09)60731-5. Type 2 diabetes mellitus after gestational diabetes: a
systematic review and meta-analysis. Bellamy L, Casas JP, Hingorani
AD, Williams D.
Women with gestational diabetes had an increased risk of developing
type 2 diabetes compared with those who had a normo glycaemic
pregnancy (RR 7.43, 95% CI 4.79-11.51)
Although the largest study (659 164 women; 9502 cases of type
2 diabetes) had the largest RR (12.6, 95% CI 12.15-13.19), RRs were
generally consistent among the subgroups assessed.
Increased awareness of the magnitude and timing of the risk of type
2 diabetes after gestational diabetes among patients and clinicians
could provide an opportunity to test and use dietary, lifestyle, and
pharmacological interventions that might prevent or delay the onset of
type 2 diabetes in affected women
106
107
Conclusions
This meta - analysis indicates a significant inverse relation of
serum 25O HD and the incidence of GDM
However, it remains unclear whether this association is causal
due to the observational study design of the studies
Clinical trials are needed to examine whether vitamin D
supplementation will improve glycemic control in women with
GDM
108
109
through:
Jan
2015.
This
topic
last
110
111
6.5 %
ayunas 126 mg
Un nivel de glucosa en
/ dl (7,0 mmol / L),
si est disponible, es tambin un diagnstico de diabetes.
Si el nivel de A1C es 5.7 a 6.4 % (39 a 46 mmol / mol), los autores
realizan un TTG con una carga de 75 gramos de Glucosa a las 2 Horas.
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Para las mujeres con DMG A1 bien controladas con la terapia mdica
nutricional sola, se siguiere no hacer prueba fetal prenatal (Grado 2C).
Ofrecemos la induccin paciente en 40 0 / 7ths semanas de gestacin.
(Grado 1C).
ECO en tercer trimestre para detectar macrosoma.
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Todas las mujeres con DMG deben tener una prueba de Tolerancia a la
Glucosa (de 2 horas) con 75 gramos entre 6 y 12 semanas despus del
parto.
Todas las mujeres deben ser alentadas a amamantar. Un posible
beneficio de la lactancia para algunas mujeres es que mejora el
metabolismo de la glucosa en el corto plazo.
Si bien cualquier tipo de anticoncepcin es aceptable, siempre y
cuando las contraindicaciones mdicas habituales para utilizar estn
ausentes, se sugiere una ATC de accin prolongada para minimizar el
riesgo de embarazo no planificado
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Conflict of interest policy All topics are updated as new evidence becomes
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Literature review current through: Jan 2015. | This topic last updated:
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Para las mujeres con diabetes, el objetivo teraputico clave durante el parto es evitar
la hiperglucemia materna, que puede aumentar el riesgo de acidemia fetal y la
hipoglucemia neonatal.
Mujeres con diabetes tipo 2 y Diabetes Gestacional generalmente producen
suficiente insulina endgena y pueden mantener la normoglucemia durante la fase
latente sin insulina exgena suplementaria. Las mujeres con diabetes tipo 1 no
tienen ninguna produccin endgena de insulina y requieren insulina basal exgeno
para mantener la euglucemia y prevenir la cetoacidosis diabtica. Durante la fase
activa, no puede ser necesaria la insulina exgena al aumento del gasto energtico
reduce las necesidades de insulina a casi cero.
Para las mujeres con diabetes tratadas con frmacos anti-hiperglucmicos antes del
parto: Monitorizacin de la glucosa durante el parto cada 2 a 4 horas durante la fase
latente, 1 a 2 horas durante la fase activa, y cada hora cuando se est infundiendo
insulina.
Las mujeres con diabetes gestacional que han mantenido euglucemia prenatal en la
dieta, estilo de vida y / o la terapia mdica rara vez desarrollan hiperglucemia durante
el parto; los niveles de glucosa en la sangre pueden ser medidos en la admisin y
luego con ms frecuencia de cada cuatro a seis horas.
Cuando los niveles de glucosa son consistentemente por debajo de los intervalos
objetivo, se necesita tratamiento mdico y un seguimiento ms frecuente, y si los
valores de glucosa son consistentemente dentro del alcance, frecuencia de
monitoreo se pueden disminuir.
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