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1.
Acta Obstet Gynecol Scand ; 99(3): 341-349, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31654401

RESUMO

INTRODUCTION: Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week-specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making. MATERIAL AND METHODS: In this population-based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week-specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management. RESULTS: For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age-specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks' gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks' gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks' gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks' gestation (77.9 excess cases per 1000 deliveries) weeks. CONCLUSIONS: The clinical decision regarding timing of delivery is complex and contingent on maternal-fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks' gestation may optimize neonatal outcomes among women with diabetes.

2.
Curr Diab Rep ; 19(10): 94, 2019 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-31473839

RESUMO

PURPOSE OF REVIEW: To review the latest evidence for dietary interventions for treatment of gestational diabetes (GDM). RECENT FINDINGS: High-quality systematic reviews demonstrate no major advantages between the low-carbohydrate or calorie-restricted diets. However, the low glycemic index (GI) diet, characterized by intake of high-quality, complex carbohydrates, demonstrated lower insulin use and reduced risk of macrosomia in multiple reviews. Recent evidence suggests the Mediterranean diet is safe in pregnancy, though trials are needed to determine its efficacy over conventional dietary advice. Currently, there are insufficient data to support the safety of the ketogenic diet for the treatment of GDM. The low GI diet may improve maternal and neonatal outcomes in GDM. The liberalized carbohydrate intake is less restrictive, culturally adaptable, and may improve long-term maternal adherence. Further research is needed to establish the optimal, most sustainable, and most acceptable medical nutrition therapy for management of women with GDM.

3.
Diabetologia ; 62(9): 1561-1574, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31278412

RESUMO

AIMS/HYPOTHESIS: We performed a systematic review and meta-analysis to determine whether exposure to maternal pre-existing diabetes in pregnancy is associated with neurocognitive or behavioural outcomes in offspring. METHODS: We searched MEDLINE, EMBASE, PsychINFO, the Cochrane Database of Systematic Reviews and Scopus for studies that examined any neurocognitive or behavioural outcomes in offspring of mothers with pre-existing diabetes in pregnancy in accordance with a published protocol (PROSPERO CRD42018109038). Title and abstract review, full-text review and data extraction were performed independently and in duplicate. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of summary measures were performed using random-effects models. RESULTS: Nineteen articles including at least 18,681 exposed and 2,856,688 control participants were identified for inclusion. Exposure to maternal pre-existing diabetes in pregnancy was associated with a lower pooled intelligence quotient in the offspring (pooled weighted mean difference -3.07 [95% CI -4.59, -1.55]; I2 = 0%) and an increased risk of autism spectrum disorders (effect estimate 1.98 [95% CI 1.46, 2.68]; I2 = 0%). There was also an increased risk of attention deficit/hyperactivity disorder (pooled HR 1.36 [95% CI 1.19, 1.55]; I2 = 0%), though this was based on only two studies. Although most studies were found to be high quality in terms of participant selection, in many studies, comparability of cohorts and adequacy of follow-up were sources of bias. CONCLUSIONS/INTERPRETATION: There is evidence to suggest that in utero exposure to maternal pre-existing diabetes is associated with some adverse neurocognitive and behavioural outcomes. It remains unclear what the role of perinatal factors is and the degree to which other environmental factors contribute to these findings.

5.
Thyroid ; 29(3): 412-420, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30595114

RESUMO

BACKGROUND: Population-, assay-, and trimester-specific reference intervals for thyroid function tests are necessary to assess thyroid status accurately and manage thyroid disease throughout pregnancy. This study's objective was to verify if the manufacturer's recommended trimester-specific reference intervals for thyroid tests and the American Thyroid Association's recommended total thyroxine (TT4) pregnancy reference intervals were verifiable and appropriate for use in the authors' multicultural population. METHODS: Blood samples were obtained from the following sources: stored frozen surplus blood from women undergoing routine aneuploidy screening (first- and second-trimester samples, n = 274), women participating in an observational cohort study (second- and third-trimester samples, n = 135), and blood collected from women presenting for assessment to the labor and delivery ward (third-trimester samples, n = 35). Exclusions included thyroid medication or disease and positive thyroid peroxidase antibodies (anti-TPO). Samples were analyzed for thyrotropin (TSH), free T4 (fT4), free triiodothyronine (fT3), TT4, and anti-TPO using the Roche Cobas 8000 Modular e602 electrochemiluminescence immunoassay. RESULTS: Nine percent of the aneuploidy screening samples were excluded prior to thyroid testing due to maternal use of thyroid medication. Six percent of analyzed samples were excluded: 5.9% with positive anti-TPO and one with a TSH >10 mIU/L. The manufacturer's recommended trimester-specific reference intervals for TSH were not verified by described standardized methods. Therefore, 95th percentile reference intervals were determined using a minimum number of samples. Reference intervals for TSH and fT4 were as follows: 9-12 weeks, 0.18-2.99 mIU/L and 11-19.2 pmol/L; second trimester, 0.11-3.98 mIU/L and 10.5-18.2 pmol/L; and third trimester, 0.48-4.71 mIU/L and 9.0-16.1 pmol/L, respectively. The TT4 reference interval after 19 weeks' gestation was 77-186 nmol/L. CONCLUSIONS: This study provides a simple approach to verify or establish trimester-specific thyroid function reference intervals in local populations. The TT4 reference interval was lower than the interval proposed by the American Thyroid Association, suggesting the need for further study of TT4 in pregnancy and reliance on locally established fT4 reference intervals after 19 weeks, especially when there are no equivalent reference intervals for TT4.


Assuntos
Doenças da Glândula Tireoide/sangue , Testes de Função Tireóidea/normas , Tireotropina/sangue , Tiroxina/sangue , Tri-Iodotironina/sangue , Adulto , Alberta , Eletroquímica , Feminino , Humanos , Luminescência , Idade Materna , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Terceiro Trimestre da Gravidez , Diagnóstico Pré-Natal , Valores de Referência , Testes de Função Tireóidea/métodos
6.
Diabetologia ; 62(2): 249-258, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30421138

RESUMO

AIMS/HYPOTHESIS: This study aimed to examine the association of maternal diabetes, being large for gestational age (LGA) and breast-feeding with being overweight or obese in pre-school-aged children. METHODS: Data on height and weight at the time of their pre-school (age 4-6 years) immunisation visit between January 2009 and August 2017, as well as breast-feeding status in the first 5 months of life, for 81,226 children born between January 2005 and August 2013 were linked with maternal hospitalisation and outpatient records and birth registry data. Children were grouped into six categories based on maternal diabetes status during pregnancy (no diabetes, gestational diabetes or pre-existing diabetes) and birthweight (appropriate for gestational age [AGA] or LGA). WHO criteria were used to identify children who were overweight or obese. RESULTS: There were 69,506 children in the no diabetes/AGA group (control), 5926 in the no diabetes/LGA group, 4563 in the gestational diabetes/AGA group, 573 in the gestational diabetes/LGA group, 480 in the pre-existing diabetes/AGA group and 178 in the pre-existing diabetes/LGA group. The rate of being overweight/obese at pre-school age ranged from 20.5% in the control group to 42.9% in the gestational diabetes/LGA group. The adjusted attributable risk per cent for LGA alone (39.4%) was significantly higher than that for maternal gestational diabetes (16.0%) or pre-existing diabetes alone (15.1%); the risk for the combinations of gestational diabetes/LGA and pre-existing diabetes/LGA were 50.1% and 39.1%, respectively. Further stratification of the pre-existing diabetes groups found the prevalence of being overweight/obese was 21.2% in the type 1/AGA group, 31.4% in the type 1/LGA group (similar to those in the no diabetes groups), 26.7% in the type 2/AGA group and 42.5% in the type 2/LGA group. Breast-feeding was associated with a lower likelihood of being overweight/obese in childhood in all groups except gestational diabetes/LGA and pre-existing diabetes/LGA (both type 1 and type 2). CONCLUSION/INTERPRETATION: LGA is a stronger marker for risk of being overweight/obese in early childhood, compared with maternal diabetes during pregnancy. Rates of being overweight/obese in childhood were highest in LGA children born to mothers with gestational diabetes or pre-existing type 2 diabetes. Breast-feeding was associated with a lower risk of being overweight/obese in childhood in the majority of children; however, this association was not maintained in LGA children of mothers with diabetes.


Assuntos
Aleitamento Materno , Diabetes Mellitus Tipo 2/complicações , Diabetes Gestacional/metabolismo , Macrossomia Fetal/etiologia , Sobrepeso/etiologia , Obesidade Pediátrica/etiologia , Índice de Massa Corporal , Criança , Pré-Escolar , Diabetes Mellitus Tipo 2/metabolismo , Feminino , Humanos , Recém-Nascido , Masculino , Sobrepeso/metabolismo , Obesidade Pediátrica/metabolismo , Gravidez , Gravidez em Diabéticas/metabolismo , Fatores de Risco
7.
Diabetes Care ; 41(12): 2471-2479, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30327362

RESUMO

OBJECTIVE: To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT). RESEARCH DESIGN AND METHODS: This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA1c. The primary outcome was change in HbA1c from randomization to 34 weeks' gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes. RESULTS: At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA1c (-0.55 ± 0.59 vs. -0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02). CONCLUSIONS: In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.


Assuntos
Diabetes Mellitus Tipo 1/tratamento farmacológico , Sistemas de Infusão de Insulina , Insulina/administração & dosagem , Complicações na Gravidez/tratamento farmacológico , Adolescente , Adulto , Glicemia/análise , Glicemia/metabolismo , Automonitorização da Glicemia , Diabetes Mellitus Tipo 1/sangue , Esquema de Medicação , Feminino , Hemoglobina A Glicada/análise , Hemoglobina A Glicada/metabolismo , Humanos , Recém-Nascido , Injeções Subcutâneas , Insulina/efeitos adversos , Gravidez , Complicações na Gravidez/sangue , Resultado da Gravidez , Qualidade de Vida , Resultado do Tratamento , Adulto Jovem
8.
BMJ Open ; 8(9): e022837, 2018 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-30196268

RESUMO

OBJECTIVE: To determine in women with subclinical hypothyroidism diagnosed in pregnancy whether levothyroxine treatment compared with control, impacts important obstetrical or childhood outcomes (specifically IQ) in randomised controlled trials. DESIGN: Systematic review and meta-analysis. STUDY ELIGIBILITY CRITERIA: Randomised trials which met all the following were included: (1) reported original data of women with subclinical hypothyroidism diagnosed in pregnancy (by any prespecified study definition); (2) randomised to either levothyroxine or control (placebo or no treatment); (3) reported obstetrical outcomes and/or childhood neurodevelopmental outcomes and (4) published from 1980 to January 2018 in either English or French language. DATA SOURCES: Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. OUTCOME MEASURES: Obstetrical, neonatal and childhood outcomes including: miscarriage, gestational hypertension, pre-eclampsia, preterm delivery, mode of delivery, neonatal intensive care unit admission, birth weight, gestational age at delivery, childhood IQ and neurodevelopmental scores. Risk of bias assessment Cochrane Risk of Bias Tool (Modified) for Quality Assessment of Randomised Controlled Trials RESULTS: Three trials of low to unclear risk of bias with 1837 participants were included. Two studies were meta-analysed for maternal and neonatal outcomes and two studies for childhood IQ. No statistically significant differences were found for any clinical outcomes with levothyroxine therapy compared with control. LIMITATIONS: Only three trials were identified for inclusion. CONCLUSIONS: This review, based on three randomised trials in women with subclinical hypothyroidism diagnosed in pregnancy, found no evidence of benefit of levothyroxine therapy on obstetrical, neonatal, childhood IQ or neurodevelopmental outcomes. Current trial evidence does not support the treatment of subclinical hypothyroidism diagnosed in pregnancy. PROSPERO REGISTRATION NUMBER: CRD4201707980.


Assuntos
Desenvolvimento Infantil/efeitos dos fármacos , Hipotireoidismo , Complicações na Gravidez , Resultado da Gravidez , Tiroxina/uso terapêutico , Doenças Assintomáticas , Criança , Feminino , Humanos , Hipotireoidismo/diagnóstico , Hipotireoidismo/tratamento farmacológico , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/tratamento farmacológico
9.
Lancet ; 390(10110): 2347-2359, 2017 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-28923465

RESUMO

BACKGROUND: Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes. METHODS: In this multicentre, open-label, randomised controlled trial, we recruited women aged 18-40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA1c). The primary outcome was change in HbA1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527. FINDINGS: Between March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA1c in pregnant women using CGM (mean difference -0·19%; 95% CI -0·34 to -0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most common adverse events were skin reactions occurring in 49 (48%) of 103 CGM participants and eight (8%) of 104 control participants during pregnancy and in 23 (44%) of 52 CGM participants and five (9%) of 57 control participants in the planning pregnancy trial. The most common serious adverse events were gastrointestinal (nausea and vomiting in four participants during pregnancy and three participants planning pregnancy). INTERPRETATION: Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use. FUNDING: Juvenile Diabetes Research Foundation, Canadian Clinical Trials Network, and National Institute for Health Research.


Assuntos
Glicemia/análise , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/tratamento farmacológico , Insulina/administração & dosagem , Monitorização Fisiológica/métodos , Resultado da Gravidez , Adolescente , Adulto , Feminino , Humanos , Internacionalidade , Variações Dependentes do Observador , Razão de Chances , Gravidez , Medição de Risco , Índice de Gravidade de Doença , Adulto Jovem
11.
Diabetes Metab Res Rev ; 33(1)2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27184133

RESUMO

OBJECTIVE: The objective of the study is to assess the impact of maternal glycaemic control and large-for-gestational-age (LGA) infant size on the risk of developing neonatal hypoglycaemia in offspring of women with type 1 diabetes and to determine possible predictors of neonatal hypoglycaemia and LGA. RESEARCH METHODS AND DESIGN: This retrospective cohort study evaluated pregnancies in 161 women with type 1 diabetes mellitus at a large urban centre between 2006 and 2010. Mean trimester A1c values were categorized into five groups. Multiple logistic regression analyses were used to examine predictors of neonatal hypoglycaemia and large-for-gestational-age (LGA). RESULTS: Hypoglycaemia occurred in 36.6% of neonates. There was not a linear association between trimester specific A1c and LGA. After adjusting for maternal age, body mass index (BMI), smoking and premature delivery, neonatal hypoglycaemia was not linearly associated with A1c in the first, second or third trimesters. LGA was the only significant predictor for neonatal hypoglycaemia (OR, 95% CI 2.51 [1.10, 5.70]) in logistic regression analysis that adjusted for glycaemic control, maternal age, smoking, prematurity and BMI. An elevated third trimester A1c increased the odds of LGA (1.81 [1.03, 3.18]) after adjustment for smoking, parity and maternal BMI. CONCLUSIONS: Large-for-gestational-age imparts a 2.5-fold increased odds of hypoglycaemia in neonates of women with type 1 diabetes and may be a better predictor of neonatal hypoglycaemia than maternal glycaemic control. Our data suggest that LGA neonates of women with type 1 diabetes should prompt increased surveillance for neonatal hypoglycaemia and that the presence of optimum maternal glycaemic control should not reduce this surveillance. Copyright © 2016 John Wiley & Sons, Ltd.


Assuntos
Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Gestacional/fisiopatologia , Macrossomia Fetal/complicações , Hipoglicemia/etiologia , Adulto , Tamanho Corporal , Feminino , Seguimentos , Idade Gestacional , Humanos , Recém-Nascido , Masculino , Gravidez , Resultado da Gravidez , Segundo Trimestre da Gravidez , Estudos Retrospectivos , Fatores de Risco
12.
Can J Diabetes ; 41(2): 156-163, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27881298

RESUMO

OBJECTIVES: We involved patients and clinicians in Alberta, Canada, to establish research priorities in gestational diabetes mellitus (GDM), using an approach based on a model proposed by the James Lind Alliance (JLA). METHODS: We adapted the 4-step JLA process to engage women with GDM and clinicians to identify uncertainties about the management of GDM. Uncertainties were identified through a survey and a review of the clinical practice guidelines (CPG). Uncertainties were short-listed by a steering committee, followed by a 1-day facilitated workshop using a nominal group format and involving a similar number of patients and clinicians, who identified the top 10 research priorities. RESULTS: Across the various survey formats, 75 individuals submitted 389 uncertainties, the majority (44; 59%) coming from patients. We removed 9 questions as being out of scope or unclear, and 41 were identified on a review of CPG, resulting in a total of 421 uncertainties. After the priority setting process, the final top 10 research priorities included questions about a simpler, more accurate and convenient screening test; risk factors for GDM; improving postpartum diabetes screening; the impact of GDM on the future health of the children; lifestyle challenges and mental health issues; safety, effectiveness and/or impact of diet and/or medication treatments; appropriate timing for delivery; and how care is provided, organized or communicated. CONCLUSIONS: These top 10 research priorities were informed through a comprehensive and transparent process involving women who have experienced GDM as well as clinicians, and they may be regarded as research priorities for GDM.


Assuntos
Diabetes Gestacional , Participação do Paciente , Pesquisa , Feminino , Humanos , Médicos/psicologia , Guias de Prática Clínica como Assunto , Gravidez , Incerteza , Mulheres/psicologia
13.
J Diabetes Complications ; 31(3): 529-536, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27916485

RESUMO

BACKGROUND: There is considerable geographic variation in gestational diabetes mellitus (GDM) rates. We used data from two Canadian provinces, British Columbia (BC) and Alberta (AB), to determine the impact of ethnicity on GDM prevalence and neonatal outcomes. RESEARCH DESIGN AND METHODS: All deliveries between 04/01/2004 and 03/31/2010 in AB (n=249,796) and BC (n=248,217) were analyzed. We calculated GDM prevalence among Chinese, South-Asian, and the general population (predominantly Caucasian) women. RESULTS: Overall GDM prevalence was 4.8% (n=12,036) in AB and 7.2% (n=17,912) in BC. In both provinces, the prevalence of GDM was significantly higher in Chinese (AB:11%; BC:13.5%) and South Asian women (AB:8.4%;BC:13.9%) compared to the general population (AB:4.2%; BC: 5.8%). Chinese women were significantly older (AB:32.7; BC:33.0years) compared to the general population (AB:29.1; BC:30.1years). The odds of GDM relative to the general-population were 2-fold higher for South Asians in both provinces and almost 3-fold higher for Chinese in BC. Among GDM cases, compared to the general population, Chinese and South Asian infants were less likely to be LGA, more likely to be SGA, and had similar neonatal mortality rates. CONCLUSIONS: Compared to the general population, GDM prevalence is higher in Chinese and South Asian Canadians. Increased maternal age is a major contributor to higher prevalence of GDM in Chinese women. GDM rates were higher in both ethnic and general population women in BC compared to AB, suggesting that in addition to differences in ethnic distribution, differences in diagnostic practices are likely contributing to observed geographic differences in GDM prevalence.


Assuntos
Diabetes Gestacional/epidemiologia , Doenças do Recém-Nascido/epidemiologia , Adolescente , Adulto , Fatores Etários , Alberta/epidemiologia , Ásia Sudeste/etnologia , Colúmbia Britânica/epidemiologia , China/etnologia , Estudos de Coortes , Diabetes Gestacional/diagnóstico , Diabetes Gestacional/etnologia , Diabetes Gestacional/fisiopatologia , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Doenças do Recém-Nascido/etnologia , Doenças do Recém-Nascido/etiologia , Masculino , Gravidez , Diagnóstico Pré-Natal , Prevalência , Sistema de Registros , Estudos Retrospectivos , Risco , Medicina Estatal , Adulto Jovem
14.
Diabetes Care ; 39(1): 55-60, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26486187

RESUMO

OBJECTIVE: The extent to which pregnant women are screened for gestational diabetes mellitus (GDM) at the population level is not known. We examined the rate, type, and timing of GDM screening and diagnostic testing in the province of Alberta, Canada. Geographic and temporal differences in screening rates, and maternal risk factors associated with lower likelihood of screening, were also determined. RESEARCH DESIGN AND METHODS: Our retrospective linked-database cohort study included 86,842 primiparous women with deliveries between 1 October 2008 and 31 December 2012. Multivariable logistic regression analysis was used to examine maternal factors associated with lower likelihood of GDM screening. RESULTS: Overall, 94% (n = 81,304) of women underwent some form of glycemic assessment in the 270 days prior to delivery. The majority (91%) received a 50-g glucose screen (GDS). Women not screened were younger and more likely to smoke and had lower maternal weight and median household income. When a diagnostic 75-g oral glucose tolerance test (OGTT) was indicated, it occurred a median of 10 (interquartile range 7, 15) days after the screen. CONCLUSIONS: GDS occurred widely in a system where it was universally recommended and paid for publicly. When indicated, a 75-g OGTT was completed within 15 days in 75% of cases. Our finding that this two-step approach was widely implemented in a timely fashion supports continued endorsement of a two-step approach to screening and diagnosis of GDM. Further research is merited to assess whether the one-step GDM diagnostic approach results in different rates and timing of the 75-g OGTT and affects pregnancy outcomes.


Assuntos
Glicemia/análise , Diabetes Gestacional/diagnóstico , Teste de Tolerância a Glucose , Programas de Rastreamento/métodos , Adulto , Fatores Etários , Alberta/epidemiologia , Estudos de Coortes , Diabetes Gestacional/epidemiologia , Feminino , Humanos , Gravidez , Prevalência , Estudos Retrospectivos
15.
Ann Intern Med ; 163(11): 836-47, 2015 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-26414020

RESUMO

BACKGROUND: Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear. PURPOSE: To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect. DATA SOURCES: 6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: 36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE). DATA SYNTHESIS: Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial. LIMITATIONS: All studies had medium or high risk of bias. There was scarce evidence for many outcomes. CONCLUSION: Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515). PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).


Assuntos
Diabetes Mellitus Tipo 1/psicologia , Diabetes Mellitus Tipo 1/terapia , Comportamentos Relacionados com a Saúde , Autocuidado , Diabetes Mellitus Tipo 1/sangue , Hemoglobina A Glicada/análise , Humanos , Estilo de Vida , Educação de Pacientes como Assunto , Qualidade de Vida
16.
Ann Intern Med ; 163(11): 848-60, 2015 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-26414227

RESUMO

BACKGROUND: Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. PURPOSE: To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. DATA SOURCES: 6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. DATA SYNTHESIS: Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants). LIMITATIONS: All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. CONCLUSION: Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).


Assuntos
Diabetes Mellitus Tipo 2/psicologia , Diabetes Mellitus Tipo 2/terapia , Comportamentos Relacionados com a Saúde , Autocuidado , Diabetes Mellitus Tipo 2/sangue , Hemoglobina A Glicada/análise , Humanos , Estilo de Vida , Educação de Pacientes como Assunto , Qualidade de Vida
17.
Diabetes Metab Res Rev ; 31(5): 476-8, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25782614

RESUMO

This commentary briefly reviews what is currently known about estimating the prevalence of gestational diabetes in indigenous women. It offers insights into numerous factors likely playing a role in its observed variability. It also highlights important key concepts to consider in the overall evaluation and management of gestational diabetes in this particular population.


Assuntos
Diabetes Gestacional/epidemiologia , Índios Norte-Americanos/estatística & dados numéricos , Inuítes/estatística & dados numéricos , Grupo com Ancestrais Oceânicos/estatística & dados numéricos , Austrália/epidemiologia , Canadá/epidemiologia , Feminino , Humanos , Grupos Populacionais/estatística & dados numéricos , Gravidez , Prevalência , Estados Unidos/epidemiologia
18.
Diabetologia ; 57(4): 681-9, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24434960

RESUMO

AIMS/HYPOTHESIS: The aim of this study was to compare glycaemic control and maternal-fetal outcomes in women with type 1 diabetes managed on insulin pumps compared with multiple daily injections of insulin (MDI). METHODS: In a retrospective study, glycaemic control and outcomes of 387 consecutive pregnancies in women with type 1 diabetes who attended specialised clinics at three centres 2006-2010 were assessed. RESULTS: Women using insulin pumps (129/387) were older and had a longer duration of diabetes, more retinopathy, smoked less in pregnancy, and had more preconception care (p < 0.01 for each). Among 113 pregnancies >20 weeks' gestation in women on insulin pumps and 218 in women on MDI, there was a significant difference in HbA1c in the first trimester (mean HbA1c 6.90 ± 0.71% (52 ± 7.8 mmol/mol) vs 7.60 ± 1.38% (60 ± 15.1 mmol/mol), p < 0.001), which persisted until the third trimester (mean HbA1c 6.49 ± 0.52% (47 ± 5.7 mmol/mol) vs 6.81 ± 0.85% (51 ± 9.3 mmol/mol), p = 0.002). Rates of diabetic ketoacidosis were similar in women on insulin pumps vs MDI (1.8% vs 3.0%, p = 0.72). Despite lower HbA1c, women on insulin pumps did not have an increased incidence of severe hypoglycaemia (8.0% vs 7.6%, p = 0.90) or more weight gain (16.3 ± 8.7 vs 15.2 ± 6.2 kg, p = 0.18). More large-for-gestational-age infants in the pump group (55.0% vs 39.2%, p = 0.007) may have resulted from confounding by parity. CONCLUSIONS/INTERPRETATION: In this large multicentre study, women using insulin pumps in pregnancy had lower HbA1c without increased risk of severe hypoglycaemia or diabetic ketoacidosis but no improvement in other pregnancy outcomes. This information can help inform care providers and patients about the glycaemic effectiveness and safety of insulin pumps in pregnancy.


Assuntos
Diabetes Mellitus Tipo 1/tratamento farmacológico , Cetoacidose Diabética/epidemiologia , Hemoglobina A Glicada/metabolismo , Hipoglicemia/epidemiologia , Sistemas de Infusão de Insulina/efeitos adversos , Insulina/administração & dosagem , Insulina/uso terapêutico , Adulto , Diabetes Mellitus Tipo 1/metabolismo , Cetoacidose Diabética/metabolismo , Feminino , Humanos , Hipoglicemia/metabolismo , Hipoglicemiantes/administração & dosagem , Hipoglicemiantes/uso terapêutico , Masculino , Gravidez , Estudos Retrospectivos , Adulto Jovem
19.
Fertil Steril ; 94(3): 1097.e9-1097.e12, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20334861

RESUMO

OBJECTIVE: To review the diagnostic possibilities that exists when the workup of amenorrhea reveals an isolated LH elevation; and to examine the effect of inhibin B on LH levels in vivo. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 20-year-old woman presented with secondary amenorrhea. Her FSH measurement was low, and the LH level was elevated. The recognition that this was an unusual pattern led to the diagnosis of a rare but very treatable inhibin B-producing thecoma, despite the fact that results on the initial pelvic ultrasound examination performed 10 months after presentation of amenorrhea were relatively unremarkable. INTERVENTION(S): Surgical removal of an ovarian thecoma. MAIN OUTCOME MEASURE(S): Gonadotropins, E2, inhibin B, menstrual bleeding, and fertility. RESULT(S): Removal of the ovarian thecoma resulted in a normalization of FSH, LH, and inhibin B levels and a return of spontaneous menses 28 days later. Pregnancy occurred with the third postoperative menstrual cycle, followed by the delivery of a healthy full-term girl. CONCLUSION(S): Inhibin B-producing sex cord granolosa-stromal cell tumors should be considered in women who present with amenorrhea with isolated LH elevations, even in the setting of a previously normal pelvic ultrasound report. Diagnostic considerations that arise in the workup of amenorrhea when there is an isolated elevation in LH that is accompanied by normal or low FSH levels are reviewed. This rare clinical presentation provides the opportunity to observe the impact of inhibin B on gonadotropins in vivo.


Assuntos
Amenorreia/diagnóstico , Inibinas/metabolismo , Hormônio Luteinizante/metabolismo , Neoplasias Ovarianas/diagnóstico , Tecoma (Neoplasia)/diagnóstico , Amenorreia/sangue , Amenorreia/etiologia , Amenorreia/metabolismo , Feminino , Humanos , Inibinas/fisiologia , Hormônio Luteinizante/sangue , Neoplasias Ovarianas/complicações , Neoplasias Ovarianas/metabolismo , Síndromes Endócrinas Paraneoplásicas/complicações , Síndromes Endócrinas Paraneoplásicas/diagnóstico , Síndromes Endócrinas Paraneoplásicas/metabolismo , Tecoma (Neoplasia)/complicações , Tecoma (Neoplasia)/metabolismo , Regulação para Cima , Adulto Jovem
20.
J Clin Endocrinol Metab ; 91(12): 4737-42, 2006 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17018649

RESUMO

CONTEXT: Mutations in mitochondrial DNA are rare etiologies of adult-onset diabetes mellitus (DM) that merit identification to 1) prevent iatrogenic lactic acidosis, 2) prompt appropriate screening of affected patients and their families, 3) provide genetic counseling, and 4) provide an opportunity to investigate strategies for preventing diabetes. OBJECTIVE: The objective of this study is to raise awareness of this rare form of adult-onset nonobese DM so that these patients are identified and provided with appropriate care. PATIENTS: We describe a kindred in which four of seven siblings have adult-onset DM and sensorineural hearing loss with a confirmed genetic mutation at position 3243 in the tRNA. Two other siblings in this kindred demonstrate different phenotypes of mitochondrial disease. INTERVENTION: The proband was treated with coenzyme Q10 for 1 yr. OUTCOME MEASURES: Outcome measures included stress thallium exercise testing and audiometry testing. RESULTS: After 1 yr of treatment of with coenzyme Q10, repeat stress thallium testing demonstrated improvement in the exercise tolerance of the proband from 7-12 min. Audiometry testing did not demonstrate a change in the rate of hearing decline. CONCLUSION: Maternally inherited diabetes and deafness is a rare cause of DM that is important to diagnose because of the unique management issues and associated comorbidities. This work highlights clues to the identification of this rare monogenic form of adult- onset diabetes.


Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/genética , Genes Ligados ao Cromossomo X , Perda Auditiva Neurossensorial/complicações , Adulto , Coenzimas , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Teste de Esforço , Feminino , Perda Auditiva Neurossensorial/genética , Humanos , Doenças Mitocondriais/diagnóstico , Doenças Mitocondriais/tratamento farmacológico , Doenças Mitocondriais/genética , Modelos Biológicos , América do Norte , Linhagem , RNA de Transferência de Leucina/genética , Ubiquinona/análogos & derivados , Ubiquinona/uso terapêutico
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