DMG Rastreamento e Diagnóstico
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O documento discute o rastreamento e diagnóstico da diabetes gestacional (DMG). A DMG afeta de 1% a 14% das gestações e está relacionada a piores desfechos maternos, obstétricos e neonatais. Embora haja consenso sobre os benefícios do tratamento da DMG, ainda há debates sobre os critérios diagnósticos ideais e sobre qual teste é o melhor para rastreamento e diagnóstico. Estudos recentes como o HAPO trouxeram novos dados, mas uniformidade nos protocolos ainda é necessária.
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DMG Rastreamento e Diagnóstico
- 1. Diabetes & Gravidez Rastreamento & Diagnóstico Alexandre Megale Médico Setor Metabolismo e Gestação
- 6. ANTES normal DIABETES MELLITUS GESTACIONAL ? DM IGT/IFG DM IGT / IFG Alterado 6-12 semanas DEPOIS GTT 75 g PREV-AGT Normal
- 7. CRITÉRIOS DIAGNÓSTICOS DM (não-gestantes) Categoria Jejum GTT 75g, 2h Normal: < 100 e < 140 IFG : 100 a 125 e < 140 IGT: < 100 e 140 - 199 DM: > 126 ou > 200 ADA, atualizado 2008 OMS, atualizado 2003 IFG: Impaired Fasting Glucose (Jejum alterado) IGT: Impaired Glucose Tolerance (Intolerância à Glicose)
- 9. Rudge MVC, Calderon IMP. Rev Bras Ginecol Obstet 2006; 28:571-4
- 10. Qual o teste melhor identifica a toxicidade da glicemia para o feto? Pettitt DJ, Jovanovic L. Do we know how to find Gestational Diabetes Mellitus ? Clin Chem 2006; 52:1633-4
- 11. FISIOPATOLOGIA Hiperglicemia Materna Hiperglicemia Fetal Hiperinsulinismo Fetal Macrossomia Distócia Tocotraumatismo Mal formações Hipoglicemia Polidrâmnio Hipóxia radicais livres Prematuridade SDR Retardo na maturação pulmonar Hemoglobina glicosilada > Afinidade por O2 eritropoiese Poliglobulia Icterícia Trombose Morte Perinatal RN FETO Hipo Mg ++ Hipo Ca ++
- 12. Russel MA, Carpenter MW, Coustan DR. Clin Obstet Gynecol 2007; 50:949-58
- 15. Tratamento ativo DMG & Resultados perinatais Crowther CA et al. NEJM 2005; 352: 2477-86
- 16. Tratamento ativo DMG & Resultados perinatais Tabela elaborada a partir de Crowther CA et al. NEJM 2005; 352: 2477-86 RR: Risco relativo * amostragem pequena para adequada análise estatística
- 26. HAPO Study The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358:1991-2002
- 27. HAPO Study – Objetivos 1 os The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358:1991-2002
- 28. HAPO Study – Objetivos 1 os The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358:1991-2002
- 29. HAPO Study – Discussão The HAPO Study Cooperative Research Group. N Engl J Med 2008; 358:1991-2002 The individual measures from the oral glucose-tolerance tests were not highly correlated, and no single measure was clearly superior in predicting the primary outcomes . When adjusted for potential confounders, relative increases in each glucose measure were similarly predictive of birth weight above the 90th percentile. When the glucose measures were analyzed as continuous variables, each was a significant predictor of primary cesarean delivery, with 1-SD increases in glucose level being associated with an increase of 8 to 11% in the odds of delivery by cesarean section. Clinical neonatal hypoglycemia was infrequent (overall incidence, 2.1%), and when adjusted for confounders, only the 1-hour plasma glucose level remained a significant predictor of this outcome. All three measures of plasma glucose were highly predictive of cord-blood serum C-peptide values, with the fasting plasma glucose level being the strongest predictor .
- 34. Fluxograma 1ª consulta FR e GJ < 85 mg/dL E Ausência FR 86 – 125 mg/dL OU Presença FR > 126mg/dL 2 valores Curva glicêmica 75g Encaminhar ao Centro de Diabetes 24 a semana Jejum < 126 mg/dL E 2h < 140mg/dL NORMAL Jejum ≥ 126 mg/dL E / OU 2h ≥ 140 mg/dL DIABETES FR = fatores de risco GJ = glicemia de jejum
- 37. Backup Slides
- 38. 1 em cada 14 gestantes! 7% das minhas gestantes ...
- 40. Rastreamento Positivo Exame Diagnóstico Normal Doente
- 41. 1ª consulta de pré-natal Rastreamento 24ª sem Grupo de BR Negativo Positivo DMG Grupo de AR Exame Diagnóstico Normal Aguardar 24ª sem
- 42. ÉPOCA DE RASTREAMENTO glicose insulina 10 semanas 20 30 33 36 39 Parto 27
- 44. 1ª consulta de pré-natal Rastreamento 24ª sem Grupo de BR Negativo Positivo DMG Grupo de AR Exame Diagnóstico Normal Aguardar 24ª sem
- 48. Rastreamento do DMG começa na 1ª consulta: Fatores de risco Glicemia jejum
- 49. OU Rastreamento POSITIVO Na 1ª consulta: Glicemia jejum: > 85 -125 mg/dL Fatores de risco: Sim
- 51. Mulheres de AR na 1ª consulta 2 ou + pontos DMG Grupo de AR GTT 100 g 0-1 ponto Aguardar 24ª sem novo exame
- 52. E Na 1ª consulta: Glicemia jejum: < 85 mg/dL Fatores de risco: Não Rastreamento NEGATIVO Aguardar 24ª sem
- 53. Rastreamento do DG com 24-28 sem: Teste com 50 g (GLT) < 130 mg/dL:Normal > 130 mg/dL:Anormal Cessar Pesquisa Exame Diagnóstico: GTT 100 g
- 54. 1ª consulta de pré-natal DMG Rastreamento 24ª sem Grupo de BR Negativo Positivo Exame Diagnóstico Normal Cessar pesquisa Cessar pesquisa
- 58. O teste de 50 g pode substituir o GTT 100 g? Mas glicemia > 200 em qualquer horário não faz diagnóstico de DM?
- 59. DG: Estratégia Rastreamento e Diagnóstico EPM 1 a consulta de pré-natal GLICEMIA de Jejum > 126 (2 vezes) DIABETES Iniciar tratamento 85-125 SUSPEITO < 85 NORMAL Com risco Sem risco aguardar 24-28 sem teste 50g <130: Cessar pesquisa GTT 100 g 2 ou + pontos: DIABETES 0 pontos: NORMAL > 130
Notas do Editor
- In 1997, Garner et al published a pilot study for a RCT consisting of 300 pregnant Canadian women with GDM. All were between 24 and 32 weeks gestation. The diagnosis of GDM was made when a plasma glucose concentration at 2 hours after a 2-hour 75 g oral glucose tolerance test (75-g OGTT) was > 135 mg/dL in the second trimester or > 173 mg/dL in the third trimester of pregnancy.7 In this study, gestations having diagnosed and treated GDM managed by tertiary level providers were compared with gestations having untreated GDM managed by blinded non-tertiary level providers. There was no significant difference between the compared groups in rates of stillbirth, birth trauma, macrosomia, neonatal hypoglycemia, or cesarean delivery . Results of the Australasian Carbohydrate Intolerance Study in Pregnancy (ACHOIS) were published in 2005. Crowther et al reported a RCT of 1000 pregnant Australian and English women with mild GDM. All had one or more risk factors forGDMor a 50 g glucose challenge test (GCT) Z 140 mg/dL. All were between 24 and 34 weeks gestation and had 75-g OGTT results of <140 mg/dL at fasting and 140 to 197 mg/dL at 2 hours consistent with impaired glucose tolerance by 198011 WHO criteria and with GDM by 1998 WHO criteria. Women with plasma glucose concentrations Z 140 mg/dL at fasting and Z 200 mg/dL at 2 hours were excluded. Random assignment to intervention or routine obstetric care was performed. Women randomized to intervention and their providers were aware of the diagnosis and their pregnancy management was provided according to local protocols for GDM. Women randomized to routine care and their providers were blinded to the diagnosis and their pregnancy management was provided according to local routine obstetric practice. The composite primary outcome, serious perinatal complication, was defined as one or more events including perinatal death, shoulder dystocia, nerve injury, or bone fracture. After adjusting for maternal age, race/ ethnicity, parity, and multiple primary end points, intervention compared with routine care was associated with a 67% lower risk of the composite serious perinatal complication [adjusted relative risk=0.33; 95% confidence interval (CI): 0.14-0.75, P =0.04]. The absolute rates of the serious perinatal complication composite were modest, 1% and 4% in the intervention and routine care groups, respectively. The risk of macrosomia (birth weight Z 4 kg) was 53% lower with intervention compared with routine care (10% vs. 21%, adjusted relative risk=0.47; 95% CI: 0.34-0.64, P <0.001). The number of women diagnosed with preeclampsia was 30% lower in the intervention group (12% vs. 18%, adjusted relative risk=0.70; 95% CI: 0.51-0.95, P =0.02), but this may have been related to the higher rate of labor induction in this group. The rate of labor induction was 31% higher in the intervention group compared with the routine care group (39% vs. 29%, adjusted relative risk=1.31; 95% CI: 1.10-1.56, P =0.003). Despite the high induction rate, there was no difference in the cesarean delivery rate between the groups (31% vs. 32%, adjusted relative risk=0.96; 95% CI: 0.80-1.16, P =0.98). Shoulder dystocia was 64% lower in the intervention group, but the CI was wide and included no difference suggesting that the study had insufficient power to detect a difference. On the other hand, neonatal hypoglycemia requiring intravenous therapy was more common in the intervention group but did not reach the level of statistical significance.
- 67% lower risk of the composite serious perinatal complication [adjusted relative risk=0.33; 95% CI: 0.14-0.75, P =0.04] Risk of macrosomia was 53% lower with intervention compared with routine care (10% vs. 21%, adjusted relative risk=0.47; 95% CI: 0.34-0.64, P <0.001). Preeclampsia was 30% lower in the intervention group (12% vs. 18%, adjusted relative risk=0.70; 95% CI:0.51-0.95, P =0.02) Rate of labor induction was 31% higher in the intervention group compared with the routine care group (39% vs. 29%, adjusted relative risk=1.31; 95% CI: 1.10-1.56, P =0.003). No difference in the cesarean delivery rate between the groups (31% vs. 32%, adjusted relative risk=0.96; 95% CI: 0.80-1.16, P =0.98) Shoulder dystocia was 64% lower in the intervention group, but the CI was wide and included no difference suggesting that the study had insufficient power to detect a difference.
- Ambas são padrão ouro. CG 100g - Critérios – pelo menos 2 valores acima de 2 desvios padrões da média determinada por coorte durante 8 anos
- Peptídeo-C sérico ≥ P90 no sangue de cordão corresponde a hiperinsulinemia fetal Colocoquei Tocotraumatismo fetal no lugar de “Birth injury”