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Páginas: 34 (8273 palabras) Publicado: 12 de marzo de 2013
Best Practice & Research Clinical Endocrinology & Metabolism 25 (2011) 945–958

Contents lists available at ScienceDirect

Best Practice & Research Clinical Endocrinology & Metabolism
journal homepage: www.elsevier.com/locate/beem

7

Pregnancy and diabetes
David R. McCance, BSc, MD, FRCP, DCH, Consultant Physician/Honorary Professor of Endocrinology *
Regional Centre for Endocrinologyand Diabetes, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK

Keywords: diabetes pregnancy gestational diabetes mellitus outcome

Despite improved obstetric surveillance and better management of maternal hyperglycaemia over the last few decades, perinatal mortality and congenital malformation rates remain several fold higher in pregnancy complicated by diabetes than in thebackground population. A worldwide increase in the prevalence of type 2 diabetes is now being realized in the pregnancy context with apparently similar or even worse outcomes to type 1 diabetes. While the relevance of periconceptual glycaemic control to maternal fetal outcome is clearly established, only around half of women with type 1 diabetes plan their pregnancy and rates are even lower in type2 diabetes. In the last 5–10 years, several landmark trials have pointed to the validity of gestational diabetes mellitus as a diagnostic entity, however translation of recently published consensus guidelines for diagnosis and screening into routine clinical practice may prove challenging. An expanding therapeutic armamentarium and increasing awareness of the long-term implications of diabeticpregnancy for both mother and child present new challenges for clinical care, research and public health. Ó 2011 Published by Elsevier Ltd.

Epidemiology A UK Confidential Enquiry into Maternal and Childhealth (2002–2003) involving over 3000 women with type 1 and type 2 diabetes in England, Wales and Northern Ireland estimated the frequency of type 1 diabetes to be 1 in 364 (0.27%) and type 2 to be1 in 955 births (0.10%).1 Type 1 diabetes dominates in northern European populations but as highlighted by a recent US survey,2 the prevalence of type 2 diabetes is increasing (up to 20% of pregnancies in certain populations) and varies

* Tel.: þ44 2890 633430; Fax: þ44 2890 310111. E-mail address: david.mccance@belfasttrust.hscni.net. 1521-690X/$ – see front matter Ó 2011 Published by ElsevierLtd. doi:10.1016/j.beem.2011.07.009

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D.R. McCance / Best Practice & Research Clinical Endocrinology & Metabolism 25 (2011) 945–958

significantly between ethnic groups and locations. This has resulted in a predominance of type 2 over type 1 diabetic patients in some diabetes clinics. The increase in GDM is compounded by obesity, which now affects about one in five women who give birth.3Pregnancy may cause or worsen obesity through excessive weight gain and obesity may complicate pregnancy by increasing the risk of fertility problems, excess fetal growth and maternal hypertensive and diabetic disorders. Classical risk factors for adverse pregnancy outcome in diabetic mothers are well recognized and will be modified to some extent by the type and duration of diabetes, glycaemiccontrol and diabetesrelated vascular complications.4 General factors include age, parity, weight, hypertension, smoking and drug abuse. Relevant obstetric factors include previous miscarriage, multiple pregnancy, nutritional deficiency, late booking and poor obstetric history. Risks to the mother include progression of preexisting diabetic complications, spontaneous abortion and in later pregnancypre-eclampsia, hydramnios, macrosomia, operative delivery and still birth, all reported to be more common in diabetic women. Iatrogenic risks relate to more intensive blood glucose control. Specific risks to the baby include both intrauterine growth retardation (small for dates) and fetal overgrowth (macrosomia). The associated risks of prematurity, operative delivery and neonatal hypoglycaemia...
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