Дисертації з теми "Exercise, Gestational diabetes mellitus"

A prática de atividade física durante a gestação está relacionada a controle de ganho de peso materno, redução de desenvolvimento de distúrbios metabólicos e síndromes hipertensivas. Está indicada também como intervenção importante no tratamento de Diabetes mellitus, distúrbio metabólico mais comum durante a gravidez. Para a orientação de um adequado programa de exercícios físicos durante o período gestacional, torna-se necessário o conhecimento do conjunto de atividades e do gasto energético de cada paciente durante este período da vida da mulher. O Objetivo do trabalho foi avaliar a taxa de atividade física durante o ciclo gravídico-puerperal e a influência do Índice de Massa Corporal (IMC) em mulheres com ou sem Diabetes Mellitus Gestacional (DMG). As pacientes foram estratificadas de acordo com presença ou ausência de diagnóstico de DMG e IMC pré- concepcional, resultando em quatro grupos com 66 participantes cada (grupo de gestação de risco habitual - GRH com IMC adequado, >=18,5 e <= 24,9 kg/m2, e IMC alterado, >= 25 kg/m e grupo com DMG com IMC adequado, >=18,5 e <= 24,9 kg/m2, e IMC alterado, >= 25 kg/m2). As pacientes selecionadas foram submetidas a análise socioeconômica e foi aplicada a versão validada para o português do Questionário de Atividade Física para Mulheres Grávidas-QAFMG (do inglês Pregnancy Physical Activity Questionnaire-PPAQ) para avaliação do nível de atividade física no período pré-gestacional, no terceiro trimestre da gestação e três meses após o parto, que foram expressos em Equivalente Metabólico da Tarefa (do inglês Metabolic Equivalent of Task-MET). Os resultados mostraram que classificaram-se como de etnia branca 54,55% das entrevistadas no grupo DMG - IMC 0; 63,10% no grupo DMG - IMC 1; 60,24% no grupo GRH- IMC 0; 53,25% no grupo GRH - IMC1; como donas de casa 49,35%; 54,76%; 62,65 e 53,25% nos respectivos grupos. Já em estado civil as porcentagens encontradas foram de 80,52%; 89,29%; 75,90% e 80,52%.A variável escolaridade mostrou que 63,03% das gestantes do grupo DMG de IMC 0, 65,48% das gestantes do grupo DMG - IMC 1, 75,90% das gestantes do 8 grupo GRH e IMC 0 e 72,73% das gestantes do grupo GRH e IMC 1 apresentava entre 8 e 11 anos de estudo. A classe econômica mais predominante em todos os grupos foi a C2 em que a renda familiar é de 1.446,24 reais. (DMG - IMC 0 = 40,26%; DMG - IMC 1 = 31,33%; GRH - IMC 0 = 43,90%; GRH - IMC 1 = 38,96%). Ao comparar as médias dos valores de MET´s encontrados na amostra, notou-se que os valores encontrados na avaliação três meses após o parto (representado pelo tempo 2) foram superiores a 1 (1,10 MET para grupo DMG de IMC adequado e 1,06 MET para IMC alterado e no grupo GRH 1,02 MET de IMC adequado e 1,07 MET de IMC alterado). Já nas análises pré-gestacional (tempo 0) e de terceiro trismestre (tempo 1), os valores foram inferiores a 1 MET. Concluiu-se que o nível de atividade física não foi influenciado pelo diagnóstico de DMG e nem pelo IMC pré- gestacional. No entanto, alterou-se de acordo com a evolução temporal, com aumento da atividade física no período pós-parto.
The practice of physical activity during pregnancy is related to the control of weight gain in the mother\'s part, and the reduced development of metabolic disorders and hypertensive syndromes. It is also indicated as an important intervention in the treatment of Diabetes mellitus, the most common metabolic disorder during pregnancy. In order to achieve an adequate program of physical exercises to be done during the gestational period, it becomes necessary the knowledge of a set of activities and the energy expenditure of each patient during this period of a woman\'s life. The goal of this study was to evaluate the rate of physical activity during the pregnancy- postpartum cycle and the influence of the Body Mass Index (BMI) in women with or without Gestational Diabetes Mellitus (GDM). Patients were stratified according to the presence or absence of the GDM diagnosis and their preconception BMI, resulting in four groups with 66 participants in each (group of gestational habitual risk - GHR with normal BMI >=18.5 and <= 24.9 kg/m², and with altered BMI, >= 25 kg/m² and group with GDM, with normal BMI, >=18.5 and <= 24.9 kg/m², and with altered BMI, >= 25 kg/m²). The selected patients were submitted to a socioeconomic analysis and to did the Portuguese-validated version of the Pregnancy Physical Activity Questionnaire (PPAQ) to assess the level of physical activity in the pregestational period, in the third trimester of gestation and three months postpartum, which were expressed in Metabolic Equivalent of Task (MET). The results showed that 54.55% of the interviewees in the GDM - BMI 0 group; 63.10% GDM - BMI 1 group; 60.24% in the GHR-BMI 0 group; 53.25% no GHR - BMI 1 group; as housewives 49.35%; 54.76%; 62.65 and 53.25% in the respective groups. Already in civil status as percentages found were of 80.52%; 89.29%; 75.90% and 80.52%. The educational variable showed that 63.03% of the pregnant women in the GDM - BMI 0 group, 65.48% of the pregnant women in the GDM - BMI 1 group, 75.90% of the pregnant women in the GRH - BMI 0 group and 72.73% of the pregnant women in the GHR - BMI 1 group had between 8 and 11 years of study. The most predominant economic class in all groups for a C2 in which the family income is 1.446,24 reais. (GDM - BMI 0 = 40.26%, DMG - BMI 1 = 31.33%, GHR - BMI 0 = 43.90%, GHR - 10 BMI 1 = 38.96%). When comparing as mean values of METs found in the sample, it was observed that the values found in the evaluation three months after childbirth (represented by time 2) were higher than 1 (1.10 MET for adequate BMI of GDM group 1.06 MET for altered BMI and no GHR 1.02 MET for adequate BMI and 1.07 MET for altered BMI). In the pre-gestational analyses (time 0) and the third trimester (time 1), the values lower than 1 MET.It was concluded that the level of physical activity was not influenced by the diagnosis of GDM neither by the pre-gestational BMI. However, it changed according to a temporal development, with increased physical activity in the postpartum period.

Introdução: O exercício físico como parte do tratamento do diabetes mellitus gestacional (DMG) pode ajudar na manutenção das concentrações da glicemia de jejum. Objetivos: Conduzir uma revisão sistemática, com metanálise de ensaios clínicos randomizados, para avaliar o efeito do exercício supervisionado e estruturado ou o efeito do aconselhamento de atividade física, em mulheres com DMG, e comparar ao pré-natal usual para o controle da glicemia. Métodos: Os estudos elegíveis foram identificados a partir das bases de dados MEDLINE, EMBASE, Web of Science, Scopus e SportDiscus até 4 de Junho de 2015. Os dados foram extraídos de ensaios clínicos randomizados que compararam o pré-natal usual ao pré-natal usual somado ao exercício supervisionado e estruturado (pelo menos uma vez na semana) ou ao aconselhamento de atividade física, pelas quais os valores de glicemia de jejum pré e pós-intervenção estavam disponíveis. A metanálise de efeitos randômicos foi conduzida para a diferença entre as médias pós-intervenção da glicemia de jejum. Resultados: Foram encontradas 664 publicações, nas quais 82 foram avaliadas pela elegibilidade e oito foram incluídas na análise final. O efeito total do exercício nas concentrações absolutas da glicemia de jejum não foi significativamente diferente (P = 0,11) comparado ao pré-natal usual. Entretanto, o aconselhamento de atividade física comparado ao pré-natal usual demonstrou uma redução significativa nas concentrações da glicemia de jejum (diferença da média ponderada -3,88 mg/dL, 95% CI-7,33 a -0,42; I2, 48%; P para heterogeneidade < 0,15). Conclusão: O exercício supervisionado ou o aconselhamento de atividade física em mulheres com DMG não foi significativamente diferente comparado ao pré-natal usual nas concentrações de glicemia de jejum. Visto que o pré-natal usual inclui algum tipo de recomendação de atividade física, estes resultados não são surpreendentes. O aconselhamento de atividade física com o pré-natal usual inclui modificações da dieta que podem motivar as mulheres com DMG a serem mais ativas e aderentes ao aconselhamento nutricional, enquanto que o exercício estruturado pode ser mais difícil de atingir.
Background: Exercise as part of the treatment for gestational diabetes mellitus (GDM) may help maintain fasting glucose concentrations. Objective: A systematic review with meta-analysis was performed to evaluate the effect of weekly-supervised exercise or physical activity (PA) counseling in GDM women compared to standard care (SC) on glycemic control. Methods: Eligible trials were identified from MEDLINE, EMBASE, Web of Science, Scopus and SportDiscus up to 4 June 2015. Data were retrieved from randomized controlled trials comparing SC with SC plus weekly-supervised (at least once a week) prenatal exercise or PA counseling for which fasting blood glucose (FBG) values pre and post intervention were available. Random-effects meta-analysis was conducted for mean difference in FBG post exercise intervention. Results: Our search yielded 664 publications of which 82 were assessed for eligibility. Eight were analyzed and all were included in the meta-analysis. The overall effect of exercise on absolute FBG concentrations was not different (P=0.11) compared to SC. However, PA counseling versus SC showed a significant reduction in the absolute FBG concentrations (weighted mean difference -3.88 mg/dL, 95% CI-7.33 to -0.42; I2, 48%; P for heterogeneity<0.15). Conclusions: Supervised exercise or PA counseling in GDM women was not significantly different compared to SC on FBG concentrations. Since SC includes some type of PA recommendation, these results are not surprising. PA counseling with SC including dietary modifications may help motivate GDM women to be more active and adherent to nutrition advice, while structured exercise may be more difficult to achieve.

Gestational diabetes mellitus (GDM) is a complex, heterogeneous disorder. As the prevalence of GDM increases, it is increasingly important to identify subgroups of women within the GDM umbrella whose pathophysiology and associated pregnancy risk necessitates a different management approach in order to optimise maternal and neonatal outcomes. Glucokinase maturity-onset diabetes of the young (GCK-MODY) and islet autoimmunity are two such clinical entities. Recently, new pregnancy-specific screening criteria (NSC) for GCK-MODY were proposed to identify women with GDM who warrant GCK genetic testing. We tested the NSC and HbA1c in a multiethnic GDM cohort. The prevalence of GCK-MODY in women with GDM was ~1%. The NSC performed well for Anglo-Celtic women, but less well for women from other ethnic backgrounds. Antepartum HbA1c was not higher in those with GCK-MODY. We report the first two cases of antepartum fetal GCK genotyping and demonstrate how knowledge of fetal GCK genotype guides the management of maternal hyperglycaemia. We examined the prevalence, clinical significance and antepartum to post-partum trajectory of glutamic acid decarboxylase autoantibodies (GADA), insulinoma-associated antigen-2 autoantibodies (IA-2A), insulin autoantibodies (IAA) and zinc transporter 8 autoantibodies (ZnT8A) in a multiethnic GDM cohort. 9.9% of women were positive for one islet autoantibody antepartum. No participant had multiple islet autoantibodies. ZnT8A were the most common islet autoantibody. For women with positive GADA, IA-2A or IAA antepartum, islet autoantibody positivity typically persisted post-partum and 20% of women had post-partum glucose levels consistent with diabetes. In contrast, women with positive ZnT8A antepartum typically demonstrated normal ZnT8A titres post-partum and normal post-partum glucose tolerance. ZnT8A may be a marker for islet autoimmunity in a proportion of women with GDM, but the clinical relevance of ZnT8A in GDM needs further research.

Gestational diabetes mellitus (GDM) can affect up to 1 in 5 of pregnancies and is associated with adverse pregnancy outcomes including pre-eclampsia, neonatal hypoglycaemia, large for gestational age, increased adiposity and birth trauma. Good glycaemic control is the key to reduce these outcomes. Diet and lifestyle modification followed by insulin as necessary is the conventional type of management. Metformin is increasingly used in pregancy but with limited evidence, its role in GDM has not been well-established. A systematic review including both randomized and non-randomized controlled studies have been conducted to evaluate the contemporary evidence of metformin in GDM. It is suggested that metformin in GDM could be a useful alternative to insulin and is regarded as the best oral anti-hyperglycaemic agent in GDM management currently. However, almost half of metformin-treated GDM patients required supplementary insulin to achieve target glucose levels (metformin failure). Women with higher metabolic risk factors are likely to develop metformin failure. A clinical cohort of metformin-treated GDM is used to develop the predictive model to identify GDM women who are at risk of metformin failure. It has been found that women identified by new IADPSG and NICE 2015 fasting criteria are highly likely to develop metformin failure. It has also been established a number of algorithm based on various baseline characters of GDM women which will help primary healthcare physicians choose the best medication for GDM management. One of the possible side-effects of metformin includes lowering of serum vitamin B12 levels whereas serum vitamin B12 deficiency during pregnancy which is associated with increased insulin resistance. It is reported that in low vitamin B12 state, offspring’s insulin resistance is found to be higher among women with high folate low B12 state. Hence, in order to fully appreciate the role of vitamin B12 deficiency in metformin failure, it is first necessary to understand the effects of folate in low vitamin B12 condition on pregnancy outcomes in GDM. It has also been found that in normal vitamin B12 GDM women, serum folate levels are negatively associated with plasma glucose levels but not low B12 state. This underlines the fact that in order for folate to have its role, it is important to have normal vitamin B12 levels. Despite increasing use of metformin, it is not yet routine to check vitamin B12 levels before it is given. It is important to understand whether vitamin B12 has a role in metformin action. Thus, the mechanism by which vitamin B12 deficiency might interfere with metformin action was studied. In vitamin B12 deficient hepatocytes, metformin stimulation of AMPK was reduced which was followed by reduced downstream signalling in lipid metabolism. This effects were reversed by vitamin B12 supplementation. Thus, it is concluded that vitamin B12 deficiency could interfere with metformin action and before metformin is given, every GDM woman should be checked for serum vitamin B12 levels and should be supplemented if deficient. Overall, vitamin B12 could play a critical role in GDM management and it is important for every GDM woman to have normal vitamin B12 levels.

Introduction: Gestational diabetes mellitus (GDM) is a significant public health concern, due to its association with short- and long-term complications in both mothers and offspring. DNA methylation and single nucleotide polymorphisms (SNPs) offer potential to serve as molecular biomarkers, which may lead to improved detection of GDM with positive effects on health outcomes. Aim: The aim of this study was to investigate whether DNA methylation and SNPs are associated with GDM and may offer potential as molecular biomarkers for GDM in South Africa (SA). Methods: This study followed a two-pronged approach. Firstly, literature searches were conducted to collate and synthesise all published articles reporting on the prevalence of GDM in SA, the screening and diagnostic strategies used, and the current status of DNA methylation and SNPs as biomarkers for GDM. Secondly, we conducted experiments to investigate global (n=201), genome-wide (n=24) and gene-specific DNA methylation (n=286) of the adiponectin gene (ADIPOQ) in whole blood of women with and without GDM, using an Enzyme-Linked Immunosorbent Assay, a methylationEPIC BeadChip Array and pyrosequencing, respectively. In addition, genotype and allele frequencies of ADIPOQ rs266729 and rs17300539, and methylenetetrahydrofolate reductase (MTHFR) rs1801133 were determined, using quantitative real-time PCR (n=449) and DNA sequencing for validation. Results: The literature search showed that the prevalence of GDM in SA has increased over the years. Furthermore, it showed that the lack of uniformity in screening and diagnosis between and within countries hamper the accurate detection of GDM. Lastly, the literature search identified several studies that support the use of DNA methylation and SNPs as potential biomarkers for GDM. Experimentally, we showed no differences in global DNA methylation between GDM and non-GDM groups. Interestingly, global DNA methylation levels were 18% (p=0.012) higher in obese compared to non-obese pregnant women. Genome-wide methylation analysis identified 1046 differentially methylated CpG sites (associated with 939 genes) (Cut-off threshold: M>0.06 and p<0.01). Among the top five CpG sites identified, one CpG mapped to the calmodulin-binding transcription activator 1 (CAMTA1) gene, which has been shown to regulate insulin production and secretion. Two CpG sites (-3410: p=0.048 and -3400: p=0.004) in the ADIPOQ promoter were hypomethylated during GDM in HIV negative, but not in HIV positive women. Lastly, no association between the ADIPOQ and MTHFR polymorphisms and GDM was observed in our population. Conclusion: To our knowledge, this is the first study to investigate the association between DNA methylation or ADIPOQ (rs266729 and rs17300539) and MTHFR (rs1801133) polymorphisms and GDM in SA. Findings suggest that gene-specific, but not global methylation nor SNPs rs266729, rs17300539 and rs1801133, may offer potential as molecular biomarkers of GDM in this population. Future longitudinal studies in larger samples that include both HIV negative and positive pregnant women are warranted to explore the candidacy of DNA methylation as molecular biomarkers for GDM.
Thesis (PhD)--University of Pretoria, 2019.
National Research Foundation (NRF) of South Africa, Thuthuka Grant (unique grant no. 99391).
South African Medical Research Council (SAMRC)
Obstetrics and Gynaecology
PhD
Unrestricted

Objectives: To examine the relationship between particular traditional risk factors and their effect on the development of gestational diabetes mellitus (GDM) and birthweight (Part 1) as well as to assess first trimester maternal biochemical predictors of development of GDM (Part 2). Methods: Part 1. A retrospective study of prospectively collected data from fifteen maternity units in North West London between 1988-2000- the St Mary's Maternity Information System (SMMIS) dataset. The dataset was modified to include only those who were nulliparous (thus ensuring that only one pregnancy per woman was included) and excluding women with pre-existing diabetes (thus studying only women who either did or didn't develop gestational diabetes). Birthweight z-scores were calculated. Part 2. A nested case-control study using first-trimester (11+0 to 13+6 weeks of gestation) samples. that were obtained as part of a large prospective observational on-going study aimed at identifying first-trimester predictors of adverse pregnancy outcomes. Maternal levels of lipids (cholesterol, low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), non-fasting triglycerides, C-reactive protein (CRP), γ-glutamyl transferase (γ- GT), adiponectin, E-selectin, tissue plasminogen activator (t-PA) and vitamin D (25(OH)D) were measured. Statistical Package for the Social Sciences (SPSS) Version 17.0 and R (version 2.11.0) was used for statistical analysis. Results Part 1. There was a strong association between advancing maternal age and increasing body mass index (BMI) on the development of GDM (p < 0.01 for both). This varied within each racial group and was more pronounced in Black African and South Asian groups. Using White European women with a BMI of 18.5-24.9 as a reference group, Black African and South Asian pregnant women had higher Odds Ratios (ORs) for GDM development within all BMI categories compared to the reference group. Maternal BMI was positively associated with birthweight z-scores within all racial groups (p < 0.001 for all) irrespective of glycaemic status but its effect was much greater in women with GDM. The difference in birthweight z-scores between GDM and non-GDM women varied according to racial group and was much higher in non-white racial groups and at high rather than at low BMIs. Part 2. Simple maternal demographic and clinical characteristics obtained at the first antenatal visit provide a good prediction of GDM. Low levels of HDL and high levels of t-PA are independent predictors of GDM. (p=0.001 and p < 0.001 respectively). First trimester maternal serum 25(OH)D levels are not associated with the development of GDM. Conclusions Maternal age and BMI interact with racial group in relation to the development of GDM. Both factors are important in the development of GDM, particularly so in Black African and South Asian women. GDM strongly accentuates the effect of BMI on birthweight, especially within non-white populations. First trimester prediction of GDM can be enhanced by the measurement of specific maternal biomarkers.

Medical Nutrition Therapy is currently the cornerstone of gestational diabetes mellitus (GDM) management, but conflicting clinical evidence has led to a lack of expert consensus. Low carbohydrate (LC) diets are popular to help lower blood glucose levels but can increase the formation of ketones (beta-hydroxybutyrate, BHB) through increased fat catabolism. While LC diets have been endorsed by endocrine societies for GDM management, findings from a well-designed observational study indicated that high 3rd trimester serum BHB levels negatively impact child intelligence. Our literature search showed a knowledge gap related to the safety of LC diets in GDM. To address this knowledge gap, we conducted a 6-week pilot, 2-arm randomised controlled trial (MAMI 1 study) comparing the effects of a Modestly Lower Carbohydrate diet (MLC, 135 g/d carbohydrate) and Routine Care (RC, 180-200 g/d carbohydrate) on blood BHB levels and GDM outcomes. While there were no differences in BHB levels between study groups (mean ± SEM, MLC 0.1 ± 0.0 vs RC 0.1 ± 0.0 mmol/L; P = 0.308), glycaemia (6.1 ± 0.1 vs 6.0 ± 0.1 mmol/L, P = 0.317) or insulin dose (14.6 ± 1.8 vs 21.2 ± 3.9 units, P = 0.126), food analysis confirmed lower carbohydrate (165 ± 7 vs 190 ± 9 g/d, P = 0.042), energy (7040 ± 240 vs 8230 ± 320 kJ/d, P = 0.006), protein (85 vs 103 g/d, P = 0.006), and micronutrient intake (including iron and iodine) in the MLC group. The most surprising finding was a statistically smaller infant head circumference in the MLC group (33.9 ± 0.1 vs 34.9 ± 0.3 cm; P = 0.046), which remained significant after adjustment for gestational weight gain, gestational age at delivery and infant sex (P = 0.043). Head circumference ranged from the 10-25th percentile in the MLC group and between 25-50th percentile for the RC diet group. Head circumference is a proxy measure for brain volume and development, therefore this finding suggests the need for caution on LC dietary advice in GDM.

Gestational diabetes mellitus (GDM) is the most common metabolic complication in pregnancy and is associated with substantial maternal and neonatal morbidity. The standard of care for GDM in most developed countries is universal mid- to late- pregnancy (24-28 weeks gestation) glucose testing. While earlier diagnosis and treatment could improve pregnancy outcomes, tools for early identification of risk for GDM are not commonly used in practice. Existing models for predicting GDM risk within the first trimester of pregnancy based on maternal risk factors perform only modestly in the clinical setting. Heavy reliance on history of GDM to predict GDM development in the current pregnancy prevents these tools from being applicable to nulliparous women (i.e., women who have never given birth). In order to offer timely preventive intervention and enhanced antenatal care to nulliparous women, we need to be able to accurately identify those at high risk for GDM early in pregnancy. Data from the California Office of Statewide Health Planning and Development Linked Birth File was used to address three aims: 1) improve early pregnancy prediction of GDM risk in nulliparous women through development of a risk factor-based model, 2) conduct a systematic review and meta-analysis assessing the relationship between first trimester prenatal screening biomarker levels and development of GDM, and 3) determine if the addition of first and second trimester prenatal screening biomarkers to risk factor-based models will improve early prediction of GDM in nulliparous women. We developed a clinical prediction model including five well-established risk factors for GDM (race/ethnicity, age at delivery, pre-pregnancy body mass index, family history of diabetes, and pre-existing hypertension). Our model had moderate predictive performance among all nulliparous women, and performed particularly well among Hispanic and Black women when assessed within specific racial/ethnic groups. Our risk prediction model also showed superior performance over the commonly used American College of Obstetricians and Gynecologists (ACOG) screening guidelines, encouraging the prompt incorporation of this tool into preconception and prenatal care. Biomarkers commonly assessed in prenatal screening have been associated with a number of adverse perinatal and birth outcomes. However, reports on the relationship between first trimester measurements of prenatal screening biomarkers and GDM development are inconsistent. Our meta-analysis demonstrated that women who are diagnosed with GDM have lower first trimester multiple of the median (MoM) levels of both pregnancy associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (free β-hCG) than women who remain normoglycemic throughout pregnancy. Findings from our meta-analysis suggested that incorporation of prenatal screening biomarkers in clinical risk prediction models could aid in earlier identification of women at risk of developing GDM. Upon linkage of California Office of Statewide Health Planning and Development Linked Birth File and California Prenatal Screening Program records, we found that decreased levels of first trimester PAPP-A, increased second trimester unconjugated estriol, and increased second trimester dimeric inhibin A were associated with GDM development in nulliparous women. However, the addition of these biomarkers in clinical models did not offer improvements to the clinical utility (i.e., risk stratification) of models including maternal risk factors alone. Our findings demonstrate that incorporation of maternal risk factors in a clinical risk prediction model can more accurately identify nulliparous women at high risk for GDM early in pregnancy compared to current standard practice. The maternal characteristics model we developed is based on clinical history and demographic variables that are already routinely collected by clinicians in the United States so that it may be easily adapted into existing prenatal care practice and screening programs. Future work should focus on evaluating the clinical impact of model implementation on maternal and infant outcomes as well as financial costs to the health care system.

Gestational diabetes mellitus (GDM), increasing in prevalence, is placing significant demands on limited health resources. In this context, to better target finite resources to those at highest risk we aimed to improve GDM risk stratification approaches and examined whether the timing of GDM diagnosis could infer risk. We found that early GDM (diagnosed before 24 weeks’ gestation) was associated with the highest risk of adverse pregnancy outcomes, despite treatment. Secondly, we explored the utility of a single HbA1c as a pragmatic index of risk at GDM diagnosis. In standard GDM, a threshold HbA1c >5.9% (41 mmol/mol) identified women at increased risk of adverse outcomes and thus baseline HbA1c would have utility as a risk stratification tool at diagnosis. In contrast, HbA1c did not have the same utility in early GDM which should be considered a high-risk cohort. These studies confirm a heterogeneity of risk within GDM and the potential utility of timing of diagnosis and baseline HbA1c as risk stratification tools. The ability in early pregnancy to accurately assess the risk for the development of GDM would allow for limited resources and preventative interventions to be applied in a targeted manner. Thus, we examined the utility of several first trimester multivariate prediction models for GDM. A clinical model achieved an area under the curve (AUC) of 0.88 [95% CI 0.85-0.92], improving on the binary clinical risk scoring systems in current use. The addition of routinely tested first trimester aneuploidy/ pre-eclampsia markers (maternal pregnancy associated plasma protein A, free-β human chorionic gonadotropin, mean arterial pressure and uterine artery pulsatility index), improved prediction and best predicted early GDM (AUC 0.96 [95% CI 0.94-0.98]). Finally, a novel multivariate risk prediction model combining previous markers, glucose, lipids and adipokine biomarkers achieved the highest detection rate for GDM for any given false positive rate of all models tested. Dependent on validation and cost benefit studies, such a model could have potential application to best define a population for GDM preventive strategies or as an alternative to universal screening. Taken together, these findings have important implications for the risk management of GDM.

The striking similarity between Gestational Diabetes Mellitus (GDM) and Type 2 Diabetes (T2D) in terms of the pathophysiologies and the risk factors has led to the hypothesis that GDM is an early manifestation of T2D, expressed under the stress of pregnancy, and therefore both diseases should share similar susceptibility genes. GDM patients may provide a more homogeneous sample for the genetic causes of the disease than T2D, and therefore make a useful group for the identification of the genes involved. Over 200 GDM affected sib-pairs from 178 families were investigated, with parents available in 40% of cases. Genomic regions from 4 different chromosomes, 6, 8, 14 and 18 were chosen from regions that showed clustering for positive linkage scores in previous linkage studies on T2D and one control region on 13, where no previous positive linkage was reported. A total of 19 microsatellite markers were analysed for linkage to GDM using sib-pair analysis. Subset analyses were performed by ranking sib-pairs on GDM-related variables, e.g. mean BMI of sibs, age at GDM episode, etc. GENEHUNTER was run multiple times, each time including the next highest ranked family in the analysis. This gave a continuous range of scores where increasing or decreasing NPL scores indicated heterogeneity associated with different environmental factors such as age and weight. To evaluate the significance of the subset analyses, the results were compared to 10,000 permutations generated by randomly ranking the sib-pairs. Using the entire dataset, the analysis showed no significant linkage to a disease locus. Positive evidence for linkage was found with the subset analysis on chromosomes 8 and 14, suggesting heterogeneity between sib-pairs in the dataset. Marker D8S1742 on 8p23 showed an NPL score of 3.01 (p=0.001) when age at GDM diagnosis was used as a covariate. Using waist-to-hip ratio (WHR), marker D14S275 on 14q12 showed an NPL score of 2.474 (p=0.006). When adjusted for multiple testing, the results were not statistically significant for linkage to a diabetes disease locus, but gave evidence that GDM and T2D share similar genetic determinants, and defined groups of siblings for follow-up analysis of both types of diabetes.

Background: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance that occurs or is first recognised during pregnancy. The prevalence of GDM is 1-28% globally and 11% in China. Although GDM can cause severe maternal and neonatal outcomes, there is no consensus worldwide as to whether universal or selective screening of expectant mothers should be recommended. In 2010, The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommended that all pregnant women should be screened via a one-step universal screening approach for GDM, using a 75g oral glucose tolerance test (OGTT) with reduced thresholds. Despite ongoing debate over the efficacy and use of the IADPSG approach, China was the first country to adopt the new screening approach. A number of observational studies have shown that the new IADSPG approach is clinically more effective. However, reservations exist as to the associated increase in health costs and inconvenience to pregnant women. Aim: To assess and explore the best screening approach for GDM both globally and in China. Methods: The research involved three projects. Project I (Chapter 3) was a systematic review of the effectiveness and cost-effectiveness of universal versus selective screening for GDM, which followed a standard systematic review procedure for Diagnostic Test Accuracy studies. Project II (Chapter 4) was a Q methodology study to investigate the pregnant women’s attitudes towards and experience of the IADPSG one-step screening approach for GDM in China. A total of 30 pregnant women who visited the hospital for antenatal care in 2014 were recruited to participate in the study. The Q methodology study was undertaken using the FlashQ software and were analysed using the PQMethod software. Project III (Chapter 5) was a case-control study to establish and assess a risk score algorithm in order to improve the IADPSG approach for GDM screening in China. Medical records of 550 pregnant women (272 GDM cases and 278 controls) who had given birth in the year 2013 at the Chengdu First People’s Hospital were retrospectively collected and analysed. Univariable analysis and multiple logistic regression analysis were used to identify GDM risk factors and to formulate the risk score algorithm. A Receiver Operating Characteristic (ROC) curve was employed to assess the effectiveness of the risk score algorithm for GDM screening. Results: The systematic review (Chapter 3) included 28 effectiveness studies, four cost studies and one cost-effectiveness study. Seven out of the 28 effectiveness studies and the cost-effectiveness study favoured selective screening. The Q methodology study (Chapter 4) suggested that the participants agreed as to the importance and necessity of the IADPSG one-step GDM screening for all pregnant women. However, the non-GDM women felt somewhat burdened in undertaking the fasting and 2-hour oral Glucose Tolerance Test (OGTT) for GDM under the IADPSG approach. The participants also desired more information on GDM and OGTT both before and after the test. The case-control study (Chapter 5) identified age, height, body mass index (BMI), family history of diabetes, waist circumference, previous deliveries and blood pressure before 24th week of gestation to be risk factors for GDM in the Chinese population. Subsequently, a risk score algorithm was established, whereby the use of the risk score to select high-risk women for screening could help to exclude nearly half (45%) of non-GDM women from the OGTT while still diagnosing 80% of the GDM cases. Conclusion: Universal screening for GDM is recommended for areas where GDM prevalence is relatively high and where economic constraints circumscribing implementation of the approach do not exist. For areas where GDM prevalence is low, it is recommended that current practice, whether it is universal or selective screening, should be retained until more robust evidence emerges. The IADPSG one-step universal screening was viewed positively in terms of importance and necessity by participants of the study, and they felt that GDM screening is necessary to be undergone by every pregnant woman. At the same time, the non-GDM women also felt strongly that the two-hour OGTT requiring 3 blood samples over the test period was inconvenient and burdensome. Alternatively, the use of a risk score-based selective IADPSG approach was observed to be conducive to the exemption of nearly half (45%) of non-GDM women from the OGTT test while still diagnosing 80% of the GDM cases in China. A future validation cohort from other parts of China is required to affirm the effectiveness of this risk scoring algorithm.

During pregnancy glucose tolerance in the mother is affected. Glucose tolerance in pregnancy, as in the non-pregnant state is a continuum, represented by a distribution curve shifted to the right, with no clear divide between normal and abnormal. Many of the problems associated with overt diabetic pregnancies can be seen in infants of GDM pregnancies, such as macrosomia, neural tube defects, neonatal hypocalcemia, birth trauma and subsequent childhood and adolescent obesity. Impaired glucose intolerance (IGT) in pregnancy is also a major risk factor for the development of NIDDM (non-insulin dependent diabetes mellitus) and IGT in later life and is associated with not only an increased risk for coronary heart disease (CHD) disease but also many other morbidities and mortalities associated with overt diabetes. The problem remaining to be resolved is the precise level of glucose intolerance in pregnancy that poses a significant risk for the later health of the mother. Nor is increased gestational glucose intolerance the only reproductive event that has been linked with future NIDDM risk. Other factors have been known to predispose pregnant women to the risk of future diabetes (e.g. BMI, age and weight change). The findings of the present study suggest that the association of glucose intolerance during pregnancy, with the subsequent incidence of diabetes and certain co-morbidities in the mother, is continuous throughout the range of glucose concentrations studied. The risk of future diabetes is also affected by certain maternal characteristics (BMI at index pregnancy and at follow-up, weight change).

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Fundação de Ensino e Pesquisa em Ciências da Saúde (FEPECS)
As alterações no metabolismo materno são importantes para suprir as demandas do feto. Entretanto, mulheres que engravidam com algum grau de resistência à insulina, como nos casos de sobrepeso/obesidade, obesidade central e síndrome dos ovários policísticos, associado à ação dos hormônios placentários anti-insulínicos favorece o quadro de hiperglicemia de intensidade variada, caracterizando o diabetes mellitus gestacional (DMG) e levando a efeitos adversos maternos e fetais. Diante da ausência de um consenso universal para o rastreamento e diagnóstico do DMG, esta revisão teve como objetivos, elencar os variados protocolos que foram propostos, bem como ressaltar os fatores de risco associados ao DMG e suas complicações. O mais recente protocolo é o da Associação Americana de Diabetes, com mudanças que se justifi cariam pelo aumento alarmante da obesidade mundial e, em decorrência, o potencial incremento na ocorrência do diabetes mellitus tipo 2, nem sempre diagnosticado antes do período gestacional. A intenção deste protocolo é identifi car as gestantes que se benefi ciariam do controle da hiperglicemia, melhorando o prognóstico destas gestações e prevenindo complicações futuras para as mães e seus filhos
Alterations in maternal metabolism are important in order to supply the demands of the fetus. However, pregnant women with some degree of insulin resistance, such as in cases of overweight/obesity, central obesity and polycystic ovaries syndrome, associated to the action of anti-insulin placental hormones, contribute to a case of hyperglycemia of varied intensity, characterizing gestational diabetes mellitus (GDM) and leading to adverse effects both maternal and fetal. At the absence of a universal consensus to the tracking and diagnosis of GDM, this review had the purpose of listing the various protocols that have been proposed, as well as highlighting the risk factors associated with GDM and its complications. The most recent protocol is the one from the American Diabetes Association, with changes that would be justifi ed by the alarming raise in worldwide obesity and, consequently, the potential increase to the occurrence of type 2 diabetes mellitus, not always diagnosed before the gestational period. The intention of this protocol is to identify the gestating women that could benefi t from hyperglycemia control, improving the prognostic of these pregnancies and preventing future complications for mothers and their children

Orientador: Iracema Mattos Paranhos
Coorientador: Sulani Silva de Souza
Banca: José Guilherme Cecatti
Banca: Maria Aparecida Mourão Brasil
Resumo: As alterações no metabolismo materno são importantes para suprir as demandas do feto. Entretanto, mulheres que engravidam com algum grau de resistência à insulina, como nos casos de sobrepeso/obesidade, obesidade central e síndrome dos ovários policísticos, associado à ação dos hormônios placentários anti-insulínicos favorece o quadro de hiperglicemia de intensidade variada, caracterizando o diabetes mellitus gestacional (DMG) e levando a efeitos adversos maternos e fetais. Diante da ausência de um consenso universal para o rastreamento e diagnóstico do DMG, esta revisão teve como objetivos, elencar os variados protocolos que foram propostos, bem como ressaltar os fatores de risco associados ao DMG e suas complicações. O mais recente protocolo é o da Associação Americana de Diabetes, com mudanças que se justifi cariam pelo aumento alarmante da obesidade mundial e, em decorrência, o potencial incremento na ocorrência do diabetes mellitus tipo 2, nem sempre diagnosticado antes do período gestacional. A intenção deste protocolo é identifi car as gestantes que se benefi ciariam do controle da hiperglicemia, melhorando o prognóstico destas gestações e prevenindo complicações futuras para as mães e seus filhos
Abstract: Alterations in maternal metabolism are important in order to supply the demands of the fetus. However, pregnant women with some degree of insulin resistance, such as in cases of overweight/obesity, central obesity and polycystic ovaries syndrome, associated to the action of anti-insulin placental hormones, contribute to a case of hyperglycemia of varied intensity, characterizing gestational diabetes mellitus (GDM) and leading to adverse effects both maternal and fetal. At the absence of a universal consensus to the tracking and diagnosis of GDM, this review had the purpose of listing the various protocols that have been proposed, as well as highlighting the risk factors associated with GDM and its complications. The most recent protocol is the one from the American Diabetes Association, with changes that would be justifi ed by the alarming raise in worldwide obesity and, consequently, the potential increase to the occurrence of type 2 diabetes mellitus, not always diagnosed before the gestational period. The intention of this protocol is to identify the gestating women that could benefi t from hyperglycemia control, improving the prognostic of these pregnancies and preventing future complications for mothers and their children
Mestre

As women who experience Gestational Diabetes Mellitus (GDM) are at considerably greater risk of developing type 2 diabetes in life, prevention of GDM is particularly important. The objectives of this research were to identify lifestyle predictors associated with GDM in a developing country and to validate a physical activity questionnaire for assessing total energy expenditure in a Pakistani population.
A prospective cohort study of 750 South Asian women recruited early in gestation was conducted in Karachi, Pakistan. Eligibility criteria included South Asian origin and ≤ 18 weeks gestation. Data on physical activity, diet, socio-demographic covariates, weight, height and body composition were obtained at recruitment and women were followed to assess GDM status at ≥ 26 weeks of gestation.
Logistic regression analysis of data from 611 women to assess the impact of age, body fat percentage, height, family history of diabetes, parity, level of education, rate of weight gain during pregnancy, and daily energy expenditure on the development of GDM was undertaken. The risk of GDM increased with increasing maternal age (yr), OR 1.13 (CI 1.06-1.21), body fat (%), OR 1.07 (CI 1.03-1.13), and decreased with daily energy expenditure (100 kcal), OR 0.89 (CI 0.79-0.99). Replacing body fat (%) with pre-gravid BMI provided similar results. Using a nested case (n=49) control (n=98) study design, conditional logistic regression analysis was conducted to assess the association between total energy, macronutrient and fiber intake and GDM. The risk of GDM decreased with increasing amounts of protein as a percentage of total energy intake, OR 0.75 (CI 0.60-0.95).
The Monitoring trends and determinants of cardiovascular disease Optional Study of Physical Activity (MOSPA) questionnaire was assessed against a Caltrac accelerometer (n=50). Subjects wore a caltrac accelerometer for 5 consecutive days. A correlation of 0.51 (P<0.01) was found between MOSPA questionnaire and Caltrac accelerometer values.
Advanced maternal age and body fat (%) predicted increased risk for GDM while physical activity was protective. Hence, prevention strategies should target increasing physical activity, sufficient to alter body composition, in this South Asian population.

Factors that influence differentially managed gestational diabetes mellitus (GDM) and variances in adherence to GDM guidelines among the South Asian women were investigated using a qualitative design. There is a lack of descriptive literature related to this topic and subsequently the need for a better understanding to provide optimal care for this population of women. A phenomenological approach provided the research approach to generate descriptive knowledge of women’s lived experience of managing and adhering to GDM guidelines. Thus, the purpose of this research was to understand the lived experiences of South Asian women managing GDM. The research question guiding the study was: What is the lived experience of managing GDM for women of South Asian descent? The results from this research study will assist health care providers to understand the experiences of South Asian women and how their experience affects their ability to effectively manage GDM. Findings from this study will aid in developing and implementing strategies that can raise awareness and contribute to successful management of GDM among this population. The overall aim is to contribute such knowledge to assist with the development of population-specific intervention strategies to enable these women to successfully manage GDM.
Applied Science, Faculty of
Nursing, School of
Graduate

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Bachelors
Health and Public Affairs
Nursing

Latinas experience disproportionate rates of gestational diabetes mellitus (GDM). Continued research efforts are necessary in order to gain a more comprehensive understanding of the factors associated with this condition among Latinas. To date, a significant amount of research has been conducted examining intrapersonal predictors of GDM. The aim of this study was to explore potential, broader-level, correlates of GDM among Latinas (N = 5,440) in California. Results from unadjusted logistic regression analyses indicated both interpersonal and community-level variables are significantly associated with GDM among Latinas. In the nested logistic regression analyses including community, interpersonal, and intrapersonal variables, one interpersonal variable (i.e., difficulty understanding the doctor) remained significant in the final model. Moreover, results suggested intrapersonal variables may mediate the relationship between community-level variables and GDM. Future research should aim to identify additional correlates, as well as examine causal mechanisms.

Gestational diabetes mellitus (GDM) is one of the most common medical complications that occurs during pregnancy, and has both immediate and long-term effects. It occurs in about 2-5% of all pregnancies. Hispanic Americans are at 1.9 times greater risk of type 2 diabetes than non-Hispanic whites of similar age. Hispanic women have higher rates of GDM than non-Hispanic white women. The purpose of this project was to describe long-term outcomes of the gestational diabetes education component of the Santa Cruz Collaborative Diabetes Project. The program, established in 1997, provides diabetes education and diabetes screening to residents of Santa Cruz County by physicians, nurse practitioners and RNs to increase awareness of and to prevent or delay the onset of diabetes and/or complications attributed to the disease in the Hispanic population. Data gathered in this project indicated that self-care and lifestyle behaviors learned during the gestational period were not all sustained in the long-term. Awareness about diabetes and its complications was evident, however, was insufficient to translate into behaviors to lower risk factors. All participants acknowledged an increased risk for developing type 2 diabetes, however, this risk was related to family history. There was no mention of GDM as a risk factor. A continued relationship with the GDM clients is recommended to ensure ongoing concern, knowledge and self-care practices that would decrease the risk of developing type 2 diabetes in these clients.

Gestational diabetes mellitus (GDM), defined as glucose intolerance first identified during pregnancy, is an escalating problem worldwide which affects 5-20% of all pregnant women. It is associated with long-term consequences such as obesity, metabolic syndrome and type 2 diabetes in both the mother and affected offspring, the latter mediated in part by birthweight (“diabetes begets diabetes”). However, selective screening strategies based on established risk factors for GDM, accurately identify only around 60% of cases suggesting that there are other mechanisms involved. The aim of my thesis was to investigate the role of 2 novel biomarkers, vitamin B12 (B12) and glucagon-like peptide (GLP-1) in the development of GDM and related metabolic outcomes. A systematic review and meta-analysis showed that B12 insufficiency in pregnancy was in the order of 20-30% across the world and was associated with marginally higher, but significant, odds of low birthweight babies but these findings may be isolated to high-risk countries. In a local UK population, B12 insufficiency was independently associated with obesity, 2.6-fold higher risk of GDM and fetal macrosomia. A nationwide survey of women of child-bearing age confirmed that 12% were B12 insufficient with associated hyperhomocysteinaemia, despite apparently adequate dietary intakes of B12. This warrants urgent review of the recommended nutrient intake guidelines to optimise B12 status prior to conception. In the second part of my thesis, it was shown that overall GLP-1 response during a diagnostic glucose tolerance test is reduced in GDM women compared to controls, with a decrease in the early phase particularly predictive of post-prandial glucose levels. This potentially provides a novel mechanism to explain the delayed first phase insulin response which has been noted in GDM and T2D. Finally, to better understand how GLP-1 may exert a protective effect on the vascular complications of hyperglycaemia, a basic science project was carried out which demonstrated that liraglutide, a GLP-1 receptor agonist, enhanced the AMPK and phospho-AKT signaling pathways thereby contributing to the reduction of oxidative cell damage. In summary, this thesis supports the hypothesis there are multiple mechanisms which give rise to GDM (e.g. predominant insulin resistance or insulin secretion or combination of factors) and biomarkers such as B12 and GLP-1 can be clinically useful in identification of high-risk women. If proven in larger prospective studies, with measurements of the biomarkers from early pregnancy, these markers may be used to risk-stratify these women with the ultimate goal of reducing the transgenerational perpetuation of diabetes.

Gestational diabetes mellitus (GDM) is a carbohydrate metabolism issue during pregnancy that is dangerous for mother and the baby. GDM occurs in 1 out of 3 diabetic women in 16.2% of live births. GDM knowledge and treatment practices among nurses were found inadequate when nurses’ effectiveness in treating a disease they have a shallow knowledge about (GDM) was investigated in the local medical facility. A GDM instructional module was applied and its effectiveness in promoting nurse’s use of GDM education as a treatment strategy tested. The total concept for knowledge and care, empowerment and the social cognitive theories grounded this research. Methodology was Mixed. A population/patient problem-intervention-comparison-outcome-time (PICOT) design was applied in the analysis of data from a sample size {n=40}, whereby the treatment group (TG=20) had an intervention, and control group (CG=20) did not. Data was analyzed descriptively and inferentially with t-test statistic, including the Cohen’s d test for effect size. Evidence showed a significantly high post-intervention gain in scores CG and TG, higher among DNPs than other nurses. Also, the Cohen’s d test indicated high magnitude effect size. Overall confidence in GDM treatment method improved. A comparison of mean test completion time and scores indicated that TG completed the posttest at a shorter time than CG. Knowledge improvement results were TG 27%; CG 2%. GDM education is an effective path to positive social change, beneficial to nurses, the medical facility and the community. Improved GDM treatment means a healthier population and increased productivity for the community. GDM education is non-medicated and more affordable - a huge savings for the community.

This thesis investigated placental histopathologies and perinatal outcomes from women with normal glycaemia, women with maternal obesity and women with gestational diabetes mellitus. The incidence of placental maturational defects were higher in the placentae from women with maternal obesity and women with gestational diabetes mellitus, suggesting that obesity and gestational diabetes mellitus may be associated with structural changes to the placenta that may affect function. In addition, this study optimised a method for extracting and amplifying microbial DNA from formalin-fixed tissue, in order to perform microbial examination in parallel with histopathology analysis using the same tissue specimen.

Introdução e objetivos – A finalidade prioritária no tratamento do diabetes mellitus gestacional (DMG) é alcançar níveis de glicemia materna tão próximos da normalidade quanto possível, a fim de reduzir os efeitos adversos associados à hiperglicemia na gestação. A auto verificação da glicemia capilar (perfil glicêmico) é o método mais usado para a monitorização do controle metabólico na gestação complicada por diabetes. Nosso objetivo foi analisar as associações entre os perfis glicêmicos maternos com os principais desfechos da gestação numa população de mulheres com DMG acompanhadas em ambulatório de pré-natal especializado em hospital universitário no sul do Brasil, Hospital de Clínicas de Porto Alegre (HCPA). Desenho e metodotologia – conduzimos um estudo de coorte prospectiva de gestantes referidas da rede de atenção primária de saúde pública para tratamento do DMG no HCPA, acompanhadas do diagnóstico ao parto. Pesquisamos associações entre os resultados dos perfis glicêmicos com o peso de nascimento e com o risco de recém-nascidos grandes para idade gestacional e de desfechos adversos perinatais. Resultados – acompanhamos 440 mulheres com DMG. A média do índice de massa corporal (IMC) foi 33.3kg/m2. 351 bebês (79.8%) mostraram peso adequado à idade gestacional no nascimento. As médias de glicemia nos perfis pré e pósprandiais aumentaram com o avanço na categoria de peso nascimento. Três ou mais perfis glicêmicos anormais foram o fator de risco mais robusto para o nascimento de bebês grandes (OR 3.15 1.51-6.55) e para o desenvolvimento de desfechos adversos perinatais (OR 2.28 1.59-3.29). O ganho de peso materno durante o tratamento associou-se ao risco de recém-nascido grande para idade gestacional, assim como o IMC pré-gestacional, esse último também fator de risco independente para eventos perinatais adversos. Conclusão – perfis glicêmicos anormais em mais de 2 ocasiões foram o fator de risco mais relacionado ao nascimento de um bebê grande para a idade gestacional e para o desenvolvimento de complicações neonatais. Efeito benéfico do tratamento do DMG, guiado pelos perfis glicêmicos, foi a maioria de recém-nascidos com peso adequado à idade gestacional nessa coorte, apesar da incidência de desfechos perinatais adversos não ter sido diferente entre as categorias de peso fetal de nascimento.
Background and objective – a priority target in the treatment of gestational diabetes mellitus (GDM) is attaining maternal glucose levels as close as possible to euglycemia, in order to decrease the adverse outcomes linked to hyperglycemia. Self-performed capillary glucose (glycemic profile) is the most widely used method for metabolic monitoring in pregnancy complicated by diabetes. We intended to analyze the associations of maternal glycemic profile to main pregnancy outcomes in a population of GDM women treated in a specialized prenatal clinic at a university hospital in South Brazil, Hospital de Clínicas de Porto Alegre (HCPA). Research design and methodology – we conducted a prospective cohort study of pregnant women, referred from public primary health care for treatment of GDM at HCPA, between 2008 and 2015. We searched associations of glycemic profiles to birth weight, large for gestational age newborn and adverse neonatal outcomes. Results – we followed 440 GDM women from diagnosis to delivery. Mean prepregnancy body mass index (BMI) was 33.3kg/m2; 351 babies (79.8%) had appropriate birth weight for gestational age. Mean glucose in pre-prandial and postprandial profiles increased with raising birth weight category. Three or more abnormal glycemic profiles showed the strongest association to a large baby (OR 3.15 1.51-6.55) and to a composite of adverse neonatal outcomes (OR 2.28 1.59- 3.29). Gestational weight gain in the course of treatment was associated to large babies, as pre-pregnancy BMI, the latter also an independent risk factor for adverse neonatal outcome. Conclusion – abnormal maternal glycemic profiles in more than two occasions were the stronger risk factor for delivering a large baby and for developing neonatal complications. A beneficial effect of GDM treatment, guided by glycemic profiles, was that most of our newborns had birth weight appropriate for gestational age, although incidence of adverse neonatal outcomes had been no different across birth weight categories.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior
The preconception care for women with Pregestational Diabetes Mellitus (DM) is recognized for its benefits to the woman and the fetus in several countries, and must be guaranteed as a strategy to reduce maternal-fetal morbidity and mortality. We aimed to analyze the preconception care for women with pregestational DM assisted at SUS, aiming to describe the specific route of pregnant women with DM in the SUS health system in Fortaleza, know the clinical and reproductive profile, check the care received in preconception and identify the knowledge regarding maternal and fetal risks. Descriptive and exploratory qualitative study carried out in four reference units for high-risk pregnancies that compose the SUS-Fortaleza, CearÃ, Brazil. Data were collected from April to September 2012, involving 41 pregnant women with pregestational DM. We used the triangulation techniques of data collection: interviews, free observation with field notes and revision of the motherâs card and/or of the medical record. The data were organized in tables and received descriptive statistical treatment; the information learned in the field notes complemented the discussion of results. The project was approved by the Ethics Committee of the Universidade Federal do CearÃ, according to Protocol number 90/12 and one met the recommendations of Resolution 196/96. The average age of the group corresponded to 30.3  5.3, age of risk for developing DM type 2, the average of education level was 9.4 Â 3.3 years, facilitator aspect for the practice of contraceptive care by women, 76.7% did not plan the current pregnancy, 26.7% were unaware of their type of DM. The prevalent time of diagnosis of DM was up to 10 years, comorbidities were reported by 33.4% of pregnant women; 56.7% of the respondents had between two and four pregnancies, with parity not over four births. The history of miscarriage and stillbirth was expected among women with pre-gestational DM who did not adopt preconceptional care and was present in 40%. About the preconception care needed for this group, the Ministry of Health recommends: glycemic control, replacement of oral hypoglycemic for insulin, control of comorbidities, monitoring of A1C, guidance on hypoglycemia and use of folic acid. Among these, the use of folic acid was being practiced by 10% of pregnant women and glucose monitoring for 6.6% of respondents. Out of these, 10% were receiving the necessary inputs to self-monitoring, when 100% should have it to recognize the best time to gestate. Regarding knowledge about maternal and fetal risks, 60% reported having gotten it in the current pregnancy. We suggest the managers of local public policies to restructure the municipal health system regarding the prenatal care of high-risk and to rescue the preconception attention in primary care.
O cuidado prÃ-concepcional de mulheres com Diabetes Mellitus (DM) prÃ-gestacional à reconhecido pelos benefÃcios à mulher e ao concepto em vÃrios paÃses, devendo ser garantido como estratÃgia para reduÃÃo da morbidade e mortalidade materno-fetal. Objetivamos analisar a atenÃÃo prÃ-concepcional de mulheres com DM prÃ-gestacional assistidas no Sistema Ãnico de SaÃde (SUS), tendo como objetivos especÃficos descrever o percurso de gestantes com DM na rede de saÃde do SUS-Fortaleza, conhecer o perfil clÃnico e reprodutivo, verificar os cuidados recebidos na prÃ-concepÃÃo e identificar o conhecimento quanto aos riscos maternos e fetais. Estudo descritivo e exploratÃrio qualitativo, realizado em quatro unidades de referÃncia para gestaÃÃo de alto risco que compÃe o SUS-Fortaleza, CearÃ, Brasil. Os dados foram coletados de abril a setembro de 2012, envolvendo 41 gestantes com DM prÃ-gestacional. Utilizamos a triangulaÃÃo de tÃcnicas de coleta de dados: entrevista, observaÃÃo livre com anotaÃÃes de campo e revisÃo do cartÃo da gestante e/ou do prontuÃrio. Os dados foram organizados em tabelas e receberem tratamento estatÃstico descritivo; as informaÃÃes apreendidas nas anotaÃÃes de campo complementaram a discussÃo dos resultados. O projeto foi aprovado pelo Comità de Ãtica em Pesquisa da Universidade Federal do CearÃ, conforme protocolo n 90/12 e foram atendidas as recomendaÃÃes da ResoluÃÃo 196/96. A mÃdia da idade do grupo correspondeu a 30,35,3, faixa etÃria de risco para o desenvolvimento do DM tipo 2; a mÃdia da escolaridade foi de 9,4Â3,3anos, aspecto facilitador a prÃtica dos cuidados prÃ-concepcionais pelas mulheres, 76,7% nÃo planejaram a gestaÃÃo atual; 26,7% desconheciam o tipo de DM. Predominou o tempo de diagnÃstico do DM atà 10 anos, as comorbidades foram referidas por 33,4% das gestantes; 56,7% das entrevistadas tinham entre duas e quatro gestaÃÃes, com paridade nÃo superior a quatro partos. O histÃrico de aborto e natimorto foi previsto entre mulheres com DM prÃ-gestacional que nÃo adotaram cuidados prÃ-concepcionais e estava presente em 40%. Sobre os cuidados prÃ-concepcionais necessÃrios a este grupo, o MinistÃrio da SaÃde preconiza: controle glicÃmico, substituiÃÃo do hipoglicemiante oral por insulina, controle das comorbidades, acompanhamento da A1C, orientaÃÃo sobre hipoglicemia e uso de Ãcido fÃlico. Entre estes, o uso de Ãcido fÃlico estava sendo praticado por 10% das gestantes e o monitoramento glicÃmico por 6,6% das entrevistadas. Destas, 10% recebiam os insumos necessÃrios ao auto monitoramento, quando 100% deveriam possuir para o reconhecimento do melhor momento de gestar. Quanto ao conhecimento sobre os riscos maternos e fetais, 60% referiu tÃ-lo adquirido na gestaÃÃo atual. Sugerimos aos gestores das polÃticas pÃblicas locais a reestruturaÃÃo da rede municipal de saÃde no que concerne à assistÃncia prÃ-natal de alto risco e ao resgate da atenÃÃo prÃ-concepcional pela atenÃÃo bÃsica.

The increasing prevalence and incidence of type 2 diabetes mellitus (T2D) has been referred to as a global epidemic. This thesis aimed to synthesise the evidence base in both animal models and human studies that exercise exposure is related to better cognition in diabetes, via 2 systematic reviews. Secondly, we investigated the efficacy of a novel form of exercise, POWER training (high velocity PRT), for cognitive function in this cohort. We hypothesised that 12 months of high intensity POWER training would significantly improve cognitive function in a cohort of older adults with T2D and multiple co-morbidities. The GREAT2DO study was the first RCT to evaluate the effects of a one-year intervention of POWER training compared to a SHAM exercise control condition on insulin resistance, HbA1c, body composition, physical performance, inflammation, adipokines, cardiovascular health status, and quality of life as well as to explore relationships between these domains in response to the intervention in this cohort. In this GREAT2DO cognitive sub-study, we assessed global cognition and several cognitive domains at baseline in relation to physical and psychological health, fitness and functional performance, as well as changes over time in cognitive outcomes in response to the intervention. We found that cognitive function improved in both POWER and sham exercise groups over time, although unexpectedly without group effect. However, we showed for the first time that there were significant direct relationships between increases in skeletal muscle mass, total muscle strength, total static balance time, and total adiponectin levels and improvements in cognitive function, and that these relationships only existed in the POWER group, as hypothesised. There is need for further study, in particular exploration of the persistence, clinical relevance, and mechanisms underlying attenuation of the rate of cognitive decline and incident dementia in this high-risk cohort.

Our objectives were to measure concentrations of glucose, insulin, insulin-like-growth-factor-binding-protein-1 (IGF BP1) and beta-hydroxybutyrate (BOHB) in amniotic fluid (AF), and establish if these concentrations were associated with emergence of maternal gestational diabetes mellitus (GDM). AF samples (n=408) were collected following routine amniocentesis (12-22 weeks gestation). Glucose and insulin concentrations were elevated in our GDM mother-infant pairs, where GDM was associated with a 176g increase in birth weight. Logistic regression showed that AF glucose but not insulin was associated with developing GDM. Non-linear Bayesian probability plots showed that when 2nd trimester glucose was plotted against insulin increases in both were predictive of the subsequent emergence of GDM. In conclusion, our findings show that: (1) AF glucose but not insulin predicts subsequent emergence of GDM and (2) these observed elevations provide evidence that the fetus of GDM mothers is being exposed early in-utero to metabolic perturbations (i.e. elevated glucose) that may have important long-term metabolic consequences for their future development.

Aims/objectives: The majority of the literature has focused upon treatments and screening routines for Gestational Diabetes Mellitus (GDM). However, knowledge about the importance and experiences of social support during pregnancy period is sparse. Social support not only affects health and well-being, but also influences pregnancy outcomes. The aims of this thesis were to 1) explore and understand importance, meaning and experiences of social support from post-natal women’ perspectives and 2) identify the sources and types of social support received/perceived during pregnancy with GDM. Method: Twelve semi-structured interviews were conducted to gain an in-depth understanding about social support during pregnancy. Data were analysed using Interpretative phenomenological analysis (IPA). Results: The findings demonstrated that women perceived the receipt of three distinct types of support. The most frequently mentioned types included: emotional support and the receipt of information/advice. Sources varied by type of support and most frequently included: HCPs and husbands/partners. This study also highlighted some of the unhelpful/disappointing experiences and recommendation to improve current services. Participants’ accounts of their experiences indicated that social support seemed to work as a protector/buffer to cope with their stressful life events, therefore improving/maintaining well-being, which represent the ‘Stress Buffering Model’ of the social support theory. Conclusion: Examples depicting the content of each type of support and unhelpful experiences revealed mental health and diabetes care related issues that can inform clinic- based social support interventions or peer discussion forum in the presence of a HCP. Recognising the importance of social support could potentially be very important to health- care during pregnancy as it is a time when health promotion and prevention are of critical importance.

Magister Pharmaceuticae - MPharm
Gestational diabetes mellitus (GDM) is a condition that affects pregnant women and is one of the most common complications related to pregnancy. According to the World health organisation (WHO), the usual window for diagnosing GDM is between 24 and 28 weeks of gestation and the primary aim of diagnosing gestational diabetes is to identify women and infants at risk of short- or longer-term adverse outcomes. Recent results from the hyperglycaemia and adverse pregnancy outcome (HAPO) study have suggested that even mild levels of hyperglycaemia can have adverse effects on foetal outcomes but there are uncertainties about the prevalence of these outcomes in GDM diagnosed according to the latest WHO 2013 guideline and/or IADPSG 2010 criteria in diverse populations. GDM prevalence has been studied by different researchers, but the prevalence of adverse foetal outcomes in GDM diagnosed based on the latest WHO 2013 guideline and/or IADPSG 2010 criteria have not yet been explored except for the data published by the HAPO study. Due to the lack of sufficient knowledge on foetal outcomes in GDM, this study was conducted to review the evidence on the prevalence of adverse foetal outcomes in GDM diagnosed according to WHO 2013 guideline and/or the IADPSG 2010 criteria. Different databases including PubMed, Science Direct, Google Scholar and CINAHL as well as bibliographic citations were searched using a well-formulated search strategy to find the relevant observational studies (prospective/retrospective cohort and case-control) using explicit inclusion and exclusion criteria. The following search terms were used, “gestational diabetes”, “pregnancy”, “adverse fetal outcomes” and “adverse foetal outcomes”. The findings of this study were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the obtained data analysed using MetaXL ® version 5.3. This review was registered online on PROSPERO, the International prospective register of systematic reviews (registration number: CRD42020155061). Fifteen studies with 88,831 pregnant women (range: 83-25,543 participants) from 12 countries around the world were identified, with a wide variation in the prevalence of foetal outcomes in GDM using the stipulated criteria. These studies were unevenly distributed geographically as six of them were conducted in Asia, four in Europe, four in North America, one in Australia and none in Africa, Antarctica and South America. A meta-analysis found that the overall prevalence of foetal outcomes ranged from 1% (perinatal mortality) to 11% ( large for gestational age). The finding is limited due to the paucity of data on the prevalence of foetal outcomes in GDM. However, more studies using these criteria in low- and middle- income countries (LMICs) are needed by health care providers, to inform practice and allocate resources for control of GDM and its adverse foetal outcomes in diverse settings and ethnic groups, especially in LMICs.

Diabetes Mellitus is a problem of global public health. It is estimated that there are over 171 million people with diabetes worldwide, and projections of the World Health Organization for 2030 suggest that the number could reach 366 million people. Thus, the aim of this study was to determine the histopathological changes in human placentas, and to describe the clinical conditions of parturien-tes diagnosed with or without Gestational Diabetes Mellitus and their newborns, there was therefore a histopathology and descriptive, pregnant women (n = 16 / group) met the authorized period from June 2015 to February 2016 at the Maternity Our Lady of Lourdes. Placentas of microscopy analysis was performed derived from pregnant women in normal placentas and conditions of pregnant women in hyperglycemic conditions, as well as analyzed the clinical conditions of these mothers. Among the maternal variables, the average weight of pregnant women showed different about the normoglycemic (73.0 kg ± 16.5) and gestational diabetes (79.0 kg ± 16.8). The mean gestational weeks showed different groups, (37,7 ± 3,37 weeks) for the group and normoglycemic (36,6 ± 1,62 weeks) for parturrientes gestational diabetes. When analyzing fetal variables, height of newborns showed different about the normoglycemic patients (49.0 cm ± 2.40) and gestational diabetes 45.8 cm ± 5.08), followed by thoracic perimeter , which was observed in normoglycemic (34.0 ± 1.69 cm) and the gestational diabetes (32.6 cm ± 1.16) respectively. It was found by assessing placental var-iables as the size of the placenta normoglycemic pregnant women was significantly higher (64.3 cm ± 9.53) when compared to gestational diabetic women (60.3 ± 11.3 cm). It was also observed as compared to the weight of the placentas of normoglycemic mothers (0.74 g ± 0.11) when compared to gestational diabetes (0.64 ± 0.16 g). The histopathological analysis showed that there was blades structural differences between the normoglycemic groups and gestational di-abetes. Having been observed that for the groups obtained in the period of 9 months were certain significant relationships between some variables, it suggests the continuity of research for a long time with more mothers to be able to relate more strikingly related factors placental changes influenced by hyperglycaemia and the pathogenesis of the disease and its relationship with maternal-fetal aggravating.
O Diabetes Mellitus é um problema de saúde pública mundial. Estima-se que existam mais de 171 milhões de pessoas com diabetes no mundo, sendo que projeções da Organização Mundial de Saúde para 2030 sugerem que esse número possa chegar a 366 milhões de pessoas. Pesquisas tem demonstrado que o Diabetes Mellitus Gestacional, pode propiciar ou agravar alterações patológicas, com possibilidades de interferir no equilíbrio sistêmico tanto da gestante quanto do feto e que os danos na placenta podem ser responsáveis por complicações materno-fetais. Sendo assim, o objetivo deste estudo foi determinar as alterações histopatológicas em placentas humanas, bem como descrever às condições clínicas de parturientes diagnosticadas com ou sem Diabetes Mellitus Gestacional e seus respectivos recém-nascidos, realizou-se, portanto, um estudo histopatológico e descritivo, de gestantes (n=16/grupo) atendidas no período autorizado de junho de 2015 a fevereiro de 2016 na Maternidade Nossa Senhora de Lourdes. Foi realizada analise microscópia de placentas oriundas de gestantes em condições normais e placentas de gestantes em condições hiperglicêmicas, bem como analisado as con-dições clínicas dessas parturientes. Entre as variáveis maternas, a média do peso das parturientes se mostrou diferente em relação as normoglicêmicas (73,0 kg ± 16,5) e as diabeticas gestacionais (79,0 kg ± 16,8). A média de semanas gestacionais mostrou-se diferentes em grupos, (37,7 semanas ± 3,37) para o grupo normoglicemicos e (36,6 semanas ± 1,62) para as parturrientes diabéticas gestacionais. Ao analisar-se as variáveis fetais, a estatura média dos recém-nascidos se mostrou diferente em relação as pacientes normoglicêmicas (49,0 cm ± 2,40) e as diabéticas gestacionais 45,8 cm ± 5,08), seguido da média do perímetro torácico, no qual observou-se nas normoglicêmicas (34,0 cm ± 1,69) e nas diabéticas gestacionais (32,6 cm ± 1,16) respectivamente. Constatou-se ao avaliar as variáveis placentárias que o tamanho da placenta das parturientes normoglicêmicas foi significativamente maior (64,3 cm ± 9,53) quando comparado a gestantes diabéticas gestacionais (60,3 cm ± 11,3). Observou-se ainda relação quanto á média do peso das placentas das parturientes normoglicêmicas (0,74 g ± 0,11) quando comparado as diabéticas gestacionais (0,64 g ± 0,16). As análises das lâminas histopatológicas demonstraram que houve diferenças estruturais entre os grupos normoglicêmicos e diabetes gestacional. Havendo-se observado que para os grupos obtidos no período de 9 meses, foram determinadas relações significativas entre algumas variáveis, sugere-se a continuidade da investigação por tempo prolongado com maior número de parturientes de modo a poder-se relacionar mais contundentemente os fatores relacionados ás alterações placentárias influenciadas pela hiperglicêmia e a patogênese da doença e a sua relação com os agravantes materno-fetais.

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Está estabelecida a associação entre diabetes mellitus (DM) tipo 2 e hipertensão arterial sistêmica (HAS). É conhecida a maior ocorrência de distúrbios hipertensivos no diabetes mellitus gestacional (DMG). No Serviço de Obstetrícia da Faculdade de Medicina de Botucatu, as gestantes são avaliadas quanto ao metabolismo da glicose por meio do teste oral de tolerância à glicose (TOTG) e o perfil glicêmico (PG), sendo classificadas em 4 grupos: IA – com ambos os testes normais, têm tolerância à glicose normal; IB – com apenas o PG alterado, têm hiperglicemia diária; IIA – com apenas o TOTG alterado, têm DMG; IIB – com ambos os testes alterados, têm DMG e hiperglicemia diária. Anteriormente, observamos maior risco de desenvolvimento de DM tipo 2 nos três grupos com distúrbios hiperglicêmicos em relação ao grupo IA. O objetivo deste estudo foi avaliar a freqüência de ocorrência de HAS nos quatro grupos gestacionais após três a 12 anos do parto. De 3113 gestantes acompanhadas pelo Serviço de Obstetrícia, foram selecionadas 551 por meio de processo aleatório e proporcional ao número de gestantes de cada grupo. Destas, puderam participar do estudo 535, assim distribuídas nos grupos: IA - 250 (100,0%); IB - 120 (100,0%); IIA - 77 (87,5%) e IIB - 88 (94,6%). As participantes eram avaliadas clinicamente e quanto à tolerância à glicose, com medição da glicemia de jejum e realização do TOTG quando a glicemia estava alterada (110 a 125 mg/dL). O estudo da associação entre a freqüência de ocorrência das variáveis e os grupos gestacionais foi feito pelo teste de Goodman. Para as variáveis quantitativas, utilizou-se a análise de variância não paramétrica na comparação entre os quatro grupos. Na análise da associação entre a pressão arterial atual e as variáveis...
High blood pressure is associated with type 2 diabetes mellitus (T2DM). There is an increased prevalence of hypertensive disorders in gestational diabetes mellitus (GDM). Glucose intolerance is evaluated at the Obstetrics Unit of Botucatu School of Medicine using the oral glucose tolerance test (OGTT) and glucose profile (GP). Pregnant women are classified into 4 groups: IA, both tests are normal - they have normal glucose tolerance; IB, only the GP is abnormal - they have habitual gestational hyperglycemia; IIA, only the OGTT is abnormal - they have GDM; and IIB, both tests are abnormal - they have GDM and habitual gestational hyperglycemia. Previously, we have observed higher risk of developing T2DM in the 3 above groups with hyperglycemic disorders in relation to the IA group. The aim of this study was to compare hypertension frequency in women among the 4 groups of glucose tolerance, 3 to 12 years after index-pregnancy. From 3,113 pregnant women followed at our Obstetrics Unit, we selected 551 by a process that was randomized and proportional to the number of pregnant women in each group. Of these, 535 could participate in this study and were distributed into the following groups: 250 (100.0%) – IA, 120 (100.0%) – IB, 77 (87.5%) – IIA, and 88 (94.6%) – IIB. The women were evaluated clinically and in relation to glucose tolerance. This was done by measuring fasting plasma glucose and performing the OGTT when plasma glucose was between 110 and 125 mg/dL. Analysis of association between frequency of the variables and the 4 groups was by Goodman’s test. Comparison between the groups in relation to quantitative variables was performed by the non-parametric analysis of variance. The c2 test analyzed the association between normal or high... (Complete abstract click electronic address below)

Orientador: Walkyria de Paula Pimenta
Resumo: Está estabelecida a associação entre diabetes mellitus (DM) tipo 2 e hipertensão arterial sistêmica (HAS). É conhecida a maior ocorrência de distúrbios hipertensivos no diabetes mellitus gestacional (DMG). No Serviço de Obstetrícia da Faculdade de Medicina de Botucatu, as gestantes são avaliadas quanto ao metabolismo da glicose por meio do teste oral de tolerância à glicose (TOTG) e o perfil glicêmico (PG), sendo classificadas em 4 grupos: IA - com ambos os testes normais, têm tolerância à glicose normal; IB - com apenas o PG alterado, têm hiperglicemia diária; IIA - com apenas o TOTG alterado, têm DMG; IIB - com ambos os testes alterados, têm DMG e hiperglicemia diária. Anteriormente, observamos maior risco de desenvolvimento de DM tipo 2 nos três grupos com distúrbios hiperglicêmicos em relação ao grupo IA. O objetivo deste estudo foi avaliar a freqüência de ocorrência de HAS nos quatro grupos gestacionais após três a 12 anos do parto. De 3113 gestantes acompanhadas pelo Serviço de Obstetrícia, foram selecionadas 551 por meio de processo aleatório e proporcional ao número de gestantes de cada grupo. Destas, puderam participar do estudo 535, assim distribuídas nos grupos: IA - 250 (100,0%); IB - 120 (100,0%); IIA - 77 (87,5%) e IIB - 88 (94,6%). As participantes eram avaliadas clinicamente e quanto à tolerância à glicose, com medição da glicemia de jejum e realização do TOTG quando a glicemia estava alterada (110 a 125 mg/dL). O estudo da associação entre a freqüência de ocorrência das variáveis e os grupos gestacionais foi feito pelo teste de Goodman. Para as variáveis quantitativas, utilizou-se a análise de variância não paramétrica na comparação entre os quatro grupos. Na análise da associação entre a pressão arterial atual e as variáveis... (Resumo completo, clicar acesso eletrônico abaixo)
Abstract: High blood pressure is associated with type 2 diabetes mellitus (T2DM). There is an increased prevalence of hypertensive disorders in gestational diabetes mellitus (GDM). Glucose intolerance is evaluated at the Obstetrics Unit of Botucatu School of Medicine using the oral glucose tolerance test (OGTT) and glucose profile (GP). Pregnant women are classified into 4 groups: IA, both tests are normal - they have normal glucose tolerance; IB, only the GP is abnormal - they have habitual gestational hyperglycemia; IIA, only the OGTT is abnormal - they have GDM; and IIB, both tests are abnormal - they have GDM and habitual gestational hyperglycemia. Previously, we have observed higher risk of developing T2DM in the 3 above groups with hyperglycemic disorders in relation to the IA group. The aim of this study was to compare hypertension frequency in women among the 4 groups of glucose tolerance, 3 to 12 years after index-pregnancy. From 3,113 pregnant women followed at our Obstetrics Unit, we selected 551 by a process that was randomized and proportional to the number of pregnant women in each group. Of these, 535 could participate in this study and were distributed into the following groups: 250 (100.0%) - IA, 120 (100.0%) - IB, 77 (87.5%) - IIA, and 88 (94.6%) - IIB. The women were evaluated clinically and in relation to glucose tolerance. This was done by measuring fasting plasma glucose and performing the OGTT when plasma glucose was between 110 and 125 mg/dL. Analysis of association between frequency of the variables and the 4 groups was by Goodman's test. Comparison between the groups in relation to quantitative variables was performed by the non-parametric analysis of variance. The c2 test analyzed the association between normal or high... (Complete abstract click electronic address below)
Mestre

O Diabetes mellitus gestacional (DMG) é uma séria condição que afeta muitas gestantes e traz muitos riscos tanto para a gestante, como para o feto. A recomendação é que se faça o rastreamento com teste oral de tolerância à glicose (TOTG) entre 24 e 28 semanas de gestação. O objetivo desse estudo é determinar a utilidade do teste de hemoglobina glicada (A1c) como teste diagnóstico de DMG, comparado com os critérios baseados na medida de glicemia. Métodos: este é um estudo de acurácia de teste diagnóstico. Nós avaliamos o metabolismo dos carboidratos através dos testes de TOTG e A1c em mulheres grávidas brasileiras atendidas nas visitas de pré-natal do Hospital de Clínicas de Porto Alegre (HCPA). Além dos testes de TOTG e A1c, foi analisada a história clínica das pacientes. O DMG foi definido de acordo com critério da American Diabetes Association (ADA) - um ou mais pontos alterados, glicemia de jejum, 1h ou 2h com concentrações de glicose plasmática ≥5.1, 10.0, ou 8.5 mmol/L, respectivamente-, ou de acordo com os critérios da Organização Mundial da Saúde (OMS) - glicemia de jejum ou 2h com concentrações de glicose plasmática ≥7.0mmol/L ou ≥7.8mmol/L, respectivamente. Presença de anemia, hemoglobinas variantes e doença renal crônica foram excluídas. Para avaliar o desempenho do teste de A1c foi utilizada a curva ROC (receiver operating characteristic curve). Resultados: um total de 262 mulheres grávidas (média de idade de 30 anos, média de idade gestacional de 26 semanas) foram avaliadas e 82 (31,3%) tiveram diagnóstico positivo (40 pelo critério da ADA e 42 pelo critério da OMS). Baseado na análise da curva ROC, considerando os critérios da ADA e OMS juntos e o TOTG como teste de referência, o ponto de corte para obter o melhor equilíbrio entre sensibilidade e especificidade (diagonal 100% a 100%) foi o valor de A1c de 31mmol/mol (5,3%). A sensibilidade e especificidade para este ponto de corte foi de 69,9% e 65,9%, respectivamente. Os pontos de corte de 40 mmol/mol (5.8%), 41 mmol⁄mol (5.9%) e 42 mmol⁄mol (6.0%) representaram especificidades de 96,1%, 96,6% e 98,3%, respectivamente. Conclusões: o teste de A1c apresenta baixa sensibilidade e alta especificidade para o diagnóstico de DMG, quando comparado com o critério tradicional. Nossos resultados mostraram que 39% dos casos de DMG foram diagnosticados usando o ponto de corte de A1c≥ 40 mmol/mol (5.8%). O teste de A1c, sozinho ou em combinação com o TOTG, talvez seja bastante útil no diagnóstico de DMG.
BACKGROUND: Gestational diabetes mellitus (GDM) is a potentially serious condition that affects many pregnancies and it carries risk for the mother and neonate. The current recommendation is to perform screening before 24 - 28 weeks of gestation by an oral glucose tolerance test (OGTT). The aim of this study is to determine the usefulness of glycated hemoglobin (A1c) as a diagnostic tool for GDM compared with the traditional criteria based on glycemia measurements. METHODS: This is a study of diagnostic test accuracy. We evaluated the status of carbohydrate metabolism by performing OGTT and A1c in Brazilian pregnant women attending prenatal visits at Hospital de Clínicas de Porto Alegre (HCPA). A1c, OGTT, and clinical history were analyzed. GDM was defined according to the American Diabetes Association (ADA) criteria (one or more fasting, 1-h, or 2-h plasma glucose concentrations ≥5.1, 10.0, or 8.5 mmol/L; respectively) or World Health Organization (WHO) criteria (fasting or 2-h plasma glucose ≥7.0mmol/L or ≥7.8mmol/L, respectively). Presence of anemia, variant hemoglobins and chronic renal disease were excluded. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance of A1c. RESULTS: A total of 262 pregnant women (mean age 30 years, mean gestational duration 26 weeks) were enrolled and 82 (31.3%) were diagnosed with diabetes (40 by ADA criteria and 42 by WHO criteria). Based on ROC curve analysis, and considering OGTT as the reference criterion, the cut-off point obtained by the point with the best equilibrium between sensitivity and specificity (100%-to-100% diagonal) was A1c value of 31 mmol⁄mol (5.3%). The sensitivity and specificity for this cut-off 27 point were 69.9 % and 65.9 %, respectively. The cut-off points of A1c of 40 mmol/mol (5.8%), 41 mmol⁄mol (5.9%) and 42 mmol⁄mol (6.0%) presented specificities of 96,1%, 96,6% and 98,3%, respectively. CONCLUSIONS: A1c test presented low sensitivity and very high specificity for GDM diagnosis when compared with traditional criteria. Our results show that 39% of GDM cases would be diagnosed by using the cut-off point A1c≥ 40 mmol/mol (5.8%) alone. A1c test, alone or in combination with OGTT, may be a very useful diagnostic tool in GDM.

Gestational diabetes Mellitus (GDM), a condition involving abnormal levels of glucose in the blood plasma has seen a rapid surge amongst the gestating mothers belonging to different regions and ethnicities around the world. Cur- rent method of screening and diagnosing GDM is restricted to Oral Glucose Tolerance Test (OGTT). With the advent of machine learning algorithms, the healthcare has seen a surge of machine learning methods for disease diag- nosis which are increasingly being employed in a clinical setup. Yet in the area of GDM, there has not been wide spread utilization of these algorithms to generate multi-parametric diagnostic models to aid the clinicians for the aforementioned condition diagnosis.In literature, there is an evident scarcity of application of machine learn- ing algorithms for the GDM diagnosis. It has been limited to the proposed use of some very simple algorithms like logistic regression. Hence, we have attempted to address this research gap by employing a wide-array of machine learning algorithms, known to be effective for binary classification, for GDM classification early on amongst gestating mother. This can aid the clinicians for early diagnosis of GDM and will offer chances to mitigate the adverse out- comes related to GDM among the gestating mother and their progeny.We set up an empirical study to look into the performance of different ma- chine learning algorithms used specifically for the task of GDM classification. These algorithms were trained on a set of chosen predictor variables by the ex- perts. Then compared the results with the existing machine learning methods in the literature for GDM classification based on a set of performance metrics. Our model couldn’t outperform the already proposed machine learning mod- els for GDM classification. We could attribute it to our chosen set of predictor variable and the under reporting of various performance metrics like precision in the existing literature leading to a lack of informed comparison.
Graviditetsdiabetes Mellitus (GDM), ett tillstånd som involverar onormala ni- våer av glukos i blodplasma har haft en snabb kraftig ökning bland de drab- bade mammorna som tillhör olika regioner och etniciteter runt om i världen. Den nuvarande metoden för screening och diagnos av GDM är begränsad till Oralt glukosetoleranstest (OGTT). Med tillkomsten av maskininlärningsalgo- ritmer har hälso- och sjukvården sett en ökning av maskininlärningsmetoder för sjukdomsdiagnos som alltmer används i en klinisk installation. Ändå inom GDM-området har det inte använts stor spridning av dessa algoritmer för att generera multiparametriska diagnostiska modeller för att hjälpa klinikerna för ovannämnda tillståndsdiagnos.I litteraturen finns det en uppenbar brist på tillämpning av maskininlär- ningsalgoritmer för GDM-diagnosen. Det har begränsats till den föreslagna användningen av några mycket enkla algoritmer som logistisk regression. Där- för har vi försökt att ta itu med detta forskningsgap genom att använda ett brett spektrum av maskininlärningsalgoritmer, kända för att vara effektiva för binär klassificering, för GDM-klassificering tidigt bland gesterande mamma. Det- ta kan hjälpa klinikerna för tidig diagnos av GDM och kommer att erbjuda chanser att mildra de negativa utfallen relaterade till GDM bland de dödande mamma och deras avkommor.Vi inrättade en empirisk studie för att undersöka prestandan för olika ma- skininlärningsalgoritmer som används specifikt för uppgiften att klassificera GDM. Dessa algoritmer tränades på en uppsättning valda prediktorvariabler av experterna. Jämfört sedan resultaten med de befintliga maskininlärnings- metoderna i litteraturen för GDM-klassificering baserat på en uppsättning pre- standametriker. Vår modell kunde inte överträffa de redan föreslagna maskininlärningsmodellerna för GDM-klassificering. Vi kunde tillskriva den valda uppsättningen prediktorvariabler och underrapportering av olika prestanda- metriker som precision i befintlig litteratur vilket leder till brist på informerad jämförelse.

A prospective cohort study was conducted in Vietnam to assess maternal lifestyle, gestational diabetes mellitus, and pregnancy outcomes. The study showed that the majority of pregnant women did not meet the recommendations for essential nutrients and physical activity during pregnancy. The prevalence of gestational diabetes was high and varied substantially according to diagnostic criteria. Caesarean section and macrosomia were the main adverse pregnancy outcomes that were more prevalent among women with gestational diabetes.

Pregnancies complicated with diabetes mellitus (DM) are associated with poor maternal and fetal outcomes, such as birth trauma, fetal overgrowth (macrosomia) and programming of the fetus to develop metabolic syndrome in adult life. Maternal hyperglycemia is thought to contribute to fetal macrosomia, however the role of the placenta in these pregnancies is incompletely understood, therefore we aimed to investigate the specific consequences of high glucose on placental metabolism. To achieve this aim an in vitro model of placental exposure to high glucose was developed. This model was used with the aim of analysing how high glucose alters the transcriptome and metabolome of these cells, using a systems biology approach to identify candidate functional pathways which may be altered in placenta as a result of hyperglycemia. These candidate functional pathways were validated in an ex vivo model of placenta exposed to high glucose and in placental tissue from pregnancies complicated by DM. A trophoblast cell line (BeWo) was cultured in low (5 mM) and high (12 mM or 25 mM) D-glucose conditions for 48 hours. Transcriptomic and metabolomic analysis of these cells was performed using microarrays, and gas- and liquid-chromatography-mass spectrometry, respectively. Transcript and metabolite changes were independently analysed and integrated, using network analysis. From the integrated analysis of the ‘omic datasets, β-fatty acid oxidation (β-FAO), purine metabolism, phosphatidylinositol/PI3K phosphate pathway and lipid metabolism, were identified as candidates for further study. Changes within the PI3K pathway and lipid metabolism/β-fatty acid oxidation were validated in an ex vivo placental explant model of high glucose and in placental tissue from women with DM, compared to uncomplicated pregnancies. mRNA, protein expression and protein activation of key molecules within the PI3K pathway were not significantly altered in placenta as a response of high glucose ex vivo or DM in vivo. The second candidate functional pathway, lipid metabolism, has previously been implicated in association with placental dysfunction in pregnancies complicated by DM. Placental fatty acid transporter and lipase protein expression, as well as, relative abundance of different fatty acids were unaltered in response to high glucose or DM. High glucose levels increased triglyceride levels within the placenta, indicating reduced rates of β-FAO. The effect of high glucose could be ameliorated using a PPARα agonist. This may provide a novel therapeutic intervention to prevent excess esterification of fatty acids to triglycerides in maternal diabetes, which may in turn influence fetal growth. This study illustrates how a systems biology approach can be used to identify novel candidate functional pathways that are altered within the trophoblast in response to high glucose. Thus, improving understanding of placental dysfunction in these pregnancies and providing novel candidate pathways for future study, which may represent potential therapeutic targets for intervention of fetal macrosomia in pregnancies complicated by DM.

Several reports have linked vitamin D deficiency with an increased risk of gestational diabetes mellitus (GDM). Both of these conditions are alarmingly common in Saudi Arabia, and pose additional risk of developing future metabolic disease. This study, therefore, investigates the vitamin D status amongst pregnant Saudi women, and the potential influence of vitamin D deficiency on metabolic dysfunction, such as GDM. A total of 578 pregnant women (28.8 ± 5.4 years) were recruited for this study during their first trimester of pregnancy (8-12 weeks) and followed up in their second trimester (24-28 weeks), where data were collected from 297 [51.3% (297/578); 28.9 ± 5.3 years] women. The study collected socio-economic, anthropometric and biochemical data, along with dietary intake, physical activity and sun indices. The findings of this study indicate that during the first trimester 81% of women being vitamin D deficient, dropping to 77% in the second trimester. It was also noted that being younger in age, multiparous, having a lower level of education, being a housewife, and living in West Riyadh were all associated with vitamin D deficiency during the first trimester (p < 0.05), and this further corresponded to reduced sun exposure (p < 0.001). In contrast, physically active pregnant women, women adequately exposed to sunlight at noon (p < 0.001), and residents of North Riyadh all had significantly higher circulating vitamin D levels (p < 0.05). Furthermore, low levels of high-density lipoprotein cholesterol (HDL-cholesterol) during early pregnancy were also associated with an increased risk of vitamin D deficiency (p < 0.05). Ultimately, compared with the first trimester, circulating vitamin D levels were significantly higher in the second trimester, after adjustment (p < 0.001). Among the pregnant women studied here, it was subsequently found that 33% developed GDM in the second trimester. Vitamin D deficiency in early pregnancy was associated with significantly higher risk of GDM, and this risk persisted after adjusting for confounding risk factors with regard to both vitamin D deficiency and GDM [odds ratio (OR) 3.97, confidence interval (CI) 1.12-14.15, p = 0.033]. In addition, significantly higher random blood glucose levels, higher glycated haemoglobin (HbA1c), and low HDL-cholesterol in early pregnancy were observed in the GDM subjects, compared to those without GDM (p < 0.05). Furthermore, vitamin D deficiency in mid-pregnancy increased the risk of metabolic syndrome and low HDL-cholesterol, thus pointing to the role of vitamin D in the probability of developing cardiometabolic disease. In summary, a high prevalence of vitamin D deficiency was observed amongst the subjects in this study, namely pregnant Saudi women. Moreover, hypovitaminosis D in early pregnancy was identified as a significant risk factor for the development of GDM. The present study, therefore, suggests that maintaining optimal levels of vitamin D during pregnancy may be a useful intervention in preventing the development of GDM and metabolic syndrome. Along with vitamin D supplementation, lifestyle modification also appears to be critical for maintaining optimal vitamin D levels during pregnancy, thus avoiding pregnancy-related complications.

Background Overweight and obesity are global health problems with several adverse health effects that threaten public health. In Sweden, almost four of ten pregnant women are overweight or obese, conditions that are associated with adverse pregnancy outcomes, including gestational diabetes mellitus (GDM), a metabolic disorder that complicates pregnancy. Globally, physical inactivity is the fourth leading risk factor for mortality. The recommendation for physical activity (i.e., ≥150 minutes/week) issued by the Professional Associations for Physical Activity and the Swedish National Board of Health and Welfare is in line with the recommendations by the WHO. Physical activity during pregnancy is generally safe and beneficial for both the pregnant woman and her fetus and can maintain or improve fitness and may further improve pregnancy outcomes. However, pregnant women tend to lower their physical activity when entering pregnancy. Midwives working in antenatal care (ANC) in Sweden play a prominent role in promoting a healthy lifestyle through counselling pregnant women on lifestyle, including physical activity during pregnancy. Individual counselling on physical activity encourages pregnant women to maintain their pre-pregnant leisure time physical activity throughout their pregnancy. Aims This thesis has three main aims. First, this thesis investigated guidelines for screening of GDM, risk factors, and pregnancy outcomes in relation to GDM. Second, it investigated physical activity during pregnancy and pregnancy outcomes. Third, it explored midwives’ and pregnant women’s experiences with counselling that addressed physical activity during pregnancy. Methods Study I and III are cross-sectional studies using data from the Maternal Health Care Register and the Salut Register. A total of 184,183 pregnant women were included in Study I (2011-2012) and 3,868 in Study III (2011-2012). Several statistical analyses were used: two-independent samples t-test, Pearson’s Chi-Square test, and univariate and multivariate logistic regression analyses. Study II and IV are qualitative studies applying qualitative content analysis. Study II included 41 midwives who were interviewed in eight focus group discussions (FGD). Study IV included 14 pregnant women who participated in individual in-depth interviews. Main findings There was no consensus in Sweden regarding clinical guidelines for screening regimes or 2-hour cut-off value for diagnosis of GDM from 2011 through 2012. Four screening regimes were applied in Sweden during this time period: A) universal screening with a 2-hour cut-off value of 10.0 mmol/L; B) selective screening with a 2-hour cut-off value of
8.9 mmol/L; C) selective screening with a 2-hour cut-off value of 10.0 mmol/L; and D) selective screening with
a 2-hour cut-off value of 12.2 mmol/L. The highest prevalence of GDM was found where selective screening was applied with a 2-hour cut-off value of 8.9 mmol/L. Unemployment, low educational level, and non-Nordic origin were all risk factors for GDM, and a BMI ≥30 kg/m2 almost four-doubled the risk for GDM compared to pregnant women with BMI <30 kg/m2. Increasing OGTT-values were associated with increasing risk of adverse pregnancy outcomes (Paper I). Midwives in antenatal care perceived counselling as both challenging and as an opportunity to promote a healthy lifestyle for pregnant women. As the theme “An on-going individual adjustment” revealed, the midwives tried to adjust their counselling to each pregnant woman’s individual needs. Counselling pregnant women on physical activity was seen as complex and ambiguous with a risk of being rejected by the women if the advice was delivered too straightforward. Instead, the midwives were “tiptoeing” around the sensitive topics (Paper II). Almost half of pregnant women reported that they achieved the recommended level of physical activity during pregnancy (i.e., ≥150 minutes/week). These pregnant women were characterized by lower BMI, higher educational level, and very good or good self-rated health (SRH) compared to the pregnant women who did not achieve the recommended level (Paper III). Pregnant women reported a desire for individual counselling on physical activity during pregnancy. The theme that emerged was “Longing for fulfilment of individual needs and expectations”, which reflected the wish that midwives’ counselling on physical activity should be based on pregnant women’s individual needs instead of merely providing general advice. Some participants reported receiving encouragement and support, but others believed they were provided insufficient counselling on physical activity and that the midwife had her own agenda focusing mostly on medical surveillance (Paper IV). Conclusions No consensus regarding clinical guidelines and diagnostic criterion for GDM existed in Sweden during 2011 to 2012. Obesity was a strong risk factor for development of GDM, and low socio-economic status and non-Nordic origin were also demonstrated as significant risk factors. Positively, almost half of the pregnant women reached the recommended level of physical activity during pregnancy. Participants fulfilling the recommendation were characterized by lower BMI, higher education, and very good or good self-rated health. Midwives strived to adjust and individualize their counselling on physical activity; however, some of the pregnant women could experience the counselling on physical activity being too general. Clearly, healthcare professionals should encourage fertile and pregnant women to be physically active, especially overweight and obese pregnant women who report low levels of physical activity, in order to improve overall health in this population.
Bakgrund Övervikt och fetma är ett stort hälsoproblem globalt med flera negativa hälsoeffekter som utgör ett hot mot folkhälsan. Nästan 40% av de gravida i Sverige har övervikt eller fetma vilket är associerat med flera negativa graviditetsutfall där graviditetsdiabetes (GDM) är en metabolisk sjukdom som komplicerar graviditeten. Fysisk inaktivitet är den fjärde ledande riskfaktorn för dödlighet i ett globalt perspektiv. Att vara fysiskt aktiv förbättrar välbefinnandet och livskvaliteten, främjar stabil vikt, insulinkänslighet och normalt blodtryck. Vidare sänker fysisk aktivitet risken för diabetes mellitus typ 2, fetma och hjärt-och kärlsjukdomar. Fysisk aktivitet under en okomplicerad graviditet är generellt att betrakta som utan risk och ökar välbefinnandet för både kvinnan och fostret. Fysisk aktivitet bidrar till att bibehålla eller förbättra fysisk kondition och kan förbättra graviditetsutfall. Trots dessa fördelar tenderar gravida att sänka sin fysiska aktivitet under graviditeten. De svenska rekommendationerna följer de internationella riktlinjerna som innebär ≥150 minuter/vecka av måttlig fysisk aktivitet alternativt 75 minuter/vecka av intensiv fysisk aktivitet eller en kombination av dessa. Svenska barnmorskor som arbetar inom mödrahälsovården i Sverige har en central, rådgivande roll gentemot gravida kvinnor när det gäller att verka för en hälsosam livsstil inkluderande fysisk aktivitet. Individuell rådgivning i fysisk aktivitet kan uppmuntra och stödja gravida kvinnor att fortsätta vara fysiskt aktiva under hela graviditeten. Syfte Att kartlägga riktlinjer för graviditetsdiabetes i Sverige samt riskfaktorer och graviditetsutfall i relation till GDM. Vidare att undersöka fysisk aktivitet under graviditeten samt associationer till graviditetsutfall och slutligen att utforska barnmorskor och gravida kvinnors upplevelser av rådgivning i fysisk aktivitet. Metod Studie I och III var tvärsnittsstudier där data från Mödrahälsovårds-registret och Salutregistret nyttjades. Totalt 184,183 gravida kvinnor inkluderades i Studie I och 3,868 inkluderades i Studie III (tidsperiod 2011-2012). Statistiska analyser som genomfördes var t-test, Pearson’s Chi-2-test och univariat samt multivariat logistisk regressionsanalys. Studie II och IV var kvalitativa studier där intervjuerna analyserades med manifest och latent kvalitativ innehållsanalys. Studie II inkluderade 41 barnmorskor i åtta fokusgrupper och 14 gravida omföderskor djupintervjuades individuellt i Studie IV. Resultat Under perioden 2011-2012 förelåg inte någon enighet gällande riktlinjer för screening och gränsvärde för diagnosen GDM i Sveriges 43 mödrahälsovårdsområden. Fyra olika screeningregimer identifierades; A) generell screening och 2-timmar gränsvärde på 10,0 mmol/L i plasmaglukos, B) selektiv screening och 2-timmar gränsvärde på 8,9 mmol/L i plasmaglukos, C) selektiv screening och 2-timmar gränsvärde på 10,0 mmol/L i plasmaglukos och D) selektiv screening och 2-timmar gränsvärde på 12,2 mmol/L i plasmaglukos. Den högsta prevalensen av GDM återfanns i det område som hade 8,9 mmol/L som gränsvärde och den lägsta där 12,2 mmol/L var gränsvärdet för GDM. Arbetslöshet, låg utbildningsnivå och ett utom-nordiskt ursprung utgjorde alla riskfaktorer för utveckling av GDM. Fetma, BMI ≥30 kg/m2, utgjorde den riskfaktor med högst risk för att utveckla GDM under graviditet med en nästan fyrdubblad risk jämfört med en kvinna med BMI <30kg/m2. Ökande 2-timmarsvärden av blodglukos var associerat med ökande negativa graviditetsutfall såsom kejsarsnitt och instrumentell vaginal förlossning (Artikel I). Barnmorskorna i mödrahälsovården upplevde rådgivningen i fysisk aktivitet som å ena sidan utmanande men å andra sidan som en möjlighet att verka för en hälsosam livsstil hos de gravida kvinnorna. Temat ”En ständigt pågående anpassning” visar barnmorskornas försök att anpassa sin rådgivning efter varje enskild gravid kvinnas behov och situation. Rådgivningen i fysisk aktivitet till gravida upplevdes som komplex och mångfacetterad. Det uttrycktes en oro för att bli avvisad av den gravida kvinnan om de givna råden förmedlades för uppriktigt. Detta ledde ibland till att barnmorskorna ”trippade på tå” och försiktigt närmade sig känsliga ämnen såsom övervikt och råd om fysisk aktivitet. Barnmorskorna försökte även finna individuella lösningar och anpassa råden utifrån varje enskild gravid kvinnas möjligheter. Detta var särskilt tydligt i mötet med kvinnor som immigrerat till Sverige, där barnmorskorna upplevde att en del av rådgivningen bestod i att slå hål på myter om fysisk aktivitet såsom något riskfyllt samt att informera om de positiva hälsoeffekterna med fysisk aktivitet under graviditeten (Artikel II). Nästan hälften av de gravida kvinnorna uppnådde Socialstyrelsens rekommendationer avseende fysisk aktivitet under graviditet och dessa kvinnor karakteriserades av lägre BMI, högre utbildningsnivå samt mycket bra/bra självskattad hälsa jämfört med de gravida som inte uppnådde rekommendationerna Artikel III). Temat som framkom i Artikel IV var ”Längtan efter tillfredsställelse av individuella behov och förväntningar” och speglar de gravidas önskan att erhålla en individuellt anpassad rådgivning i fysisk aktivitet av barnmorskorna istället för en generell rådgivning avsedd för alla. Några gravida hade erfarenheter av barnmorskan som stöttande och uppmuntrande i sin rådgivning i fysisk aktivitet. Andra kunde uppleva rådgivningen som otillräcklig, att barnmorskan exempelvis inte hade tillräckligt med kunskap i fysisk aktivitet samt att barnmorskan hade en egen agenda för deras möten som i huvudsak fokuserade på den medicinska övervakningen av graviditeten. Slutsats Under perioden 2011-2012 förelåg ingen consensus angående de nationella riktlinjerna och diagnostiska värdet för GDM i Sverige. Fetma var den riskfaktor med högst risk för utvecklande av GDM och låg socio-ekonomi, maternell ålder >35 år samt utom-nordiskt ursprung utgjorde även riskfaktorer för GDM. Positivt var att nästan hälften av de gravida uppnådde Socialstyrelsens rekommendationer för fysisk aktivitet under graviditeten och dessa karakteriserades av signifikant lägre BMI, högre utbildningsnivå samt mycket god/god självskattad hälsa. Trots att barnmorskorna beskrev hur de strävade efter att anpassa rådgivningen i fysisk aktivitet till varje enskild kvinna, kunde de gravida kvinnorna uppleva att rådgivningen var otillräcklig, för generell och främst fokuserad på den medicinska övervakningen. Det är av största vikt att hälso- och sjukvårdspersonal som möter fertila och gravida kvinnor verkar för en hälsosam livsstil, särskilt avseende kvinnor med en inaktiv livsstil och de som har övervikt eller fetma för att på så sätt förbättra hälsan hos denna del av befolkningen. För att uppnå detta krävs resurser gällande personal, tidsutrymme samt fortbildning inom hälsa och rådgivning för barnmorskor och annan hälso- och sjukvårdspersonal som möter dessa kvinnor. Slutligen, för att möjliggöra rådgivning som avser att stödja fysisk aktivitet för de kvinnor som immigrerat till Sverige behövs mer kunskap och utbildning i mötet med dessa kvinnor.

Gestational diabetes (GDM) occurs in up to 9% of pregnancies. Perinatal depression affects up to 20% of women during pregnancy, and can extend into the postpartum period. A number of studies have linked depression and diabetes, however, whether this applies to GDM or which might come first is less understood. The purpose of this study was to examine the potential relationship between depression identified in the first trimester of pregnancy and the subsequent development of GDM. Women without pre-existing Type I/II diabetes (n = 1021) were evaluated for depression during the first trimester of pregnancy, and medical records were reviewed to identify a positive history of diabetes. Women identified as depressed during the first trimester were more likely to have GDM compared to those not depressed. After controlling for demographic factors and weight-related variables level of depression in the first trimester still predicted later GDM development. Depression identified in early pregnancy may predict increased risk of subsequent GDM development. Due to the numerous maternal, fetal and neonatal complications associated with GDM, early recognition is essential to promote the best possible outcomes for mother and infant. Recognizing depression as a possible risk factor for GDM development could lead to earlier screening and preventative measures.