Consensus document
Diabetes mellitus and pregnancy. Updated clinical practice guideline 2021. Executive summary
Diabetes mellitus y embarazo. Guía de práctica clínica actualizada 2021. Resumen ejecutivo
Servicio de Endocrinología, Hospital Universitari Son Espases, Palma de Mallorca, Spain
Read
2784
Timeswas read the article
359
Total PDF
2425
Total HTML
Share statistics
array:23 [ "pii" => "S2530018022001639" "issn" => "25300180" "doi" => "10.1016/j.endien.2021.12.006" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1286" "copyright" => "SEEN and SED" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Endocrinol Diabetes Nutr. 2023;70 Supl 1:1-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S2530016422000684" "issn" => "25300164" "doi" => "10.1016/j.endinu.2021.12.014" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1286" "copyright" => "SEEN y SED" "documento" => "article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Endocrinol Diabetes Nutr. 2023;70 Supl 1:1-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Documento de consenso</span>" "titulo" => "Diabetes mellitus y embarazo. Guía de práctica clínica actualizada 2021. Resumen ejecutivo" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "6" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Diabetes mellitus and pregnancy. Updated clinical practice guideline 2021. Executive summary" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1510 "Ancho" => 2508 "Tamanyo" => 254020 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estrategia diagnóstica de diabetes gestacional en el embarazo (dos pasos). SOG: sobrecarga oral de glucosa de 100g; * Opcionalmente se puede realizar test de O'Sullivan de 50g.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Goya, Merce Codina" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Maria" "apellidos" => "Goya" ] 1 => array:2 [ "nombre" => "Merce" "apellidos" => "Codina" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2530018022001639" "doi" => "10.1016/j.endien.2021.12.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2530018022001639?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2530016422000684?idApp=UINPBA00004N" "url" => "/25300164/00000070000000S1/v3_202306211155/S2530016422000684/v3_202306211155/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2530018022001640" "issn" => "25300180" "doi" => "10.1016/j.endien.2022.11.006" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1290" "copyright" => "SEEN and SED" "documento" => "article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Endocrinol Diabetes Nutr. 2023;70 Supl 1:7-26" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Consensus document</span>" "titulo" => "Consensus document on the management of hyponatraemia of the Acqua Group of the Spanish Society of Endocrinology and Nutrition" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "7" "paginaFinal" => "26" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso sobre el manejo de la hiponatremia del Grupo Acqua de la Sociedad Española de Endocrinología y Nutrición" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1613 "Ancho" => 2343 "Tamanyo" => 351727 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Adjustment protocol for outpatient tolvaptan treatment in patients with syndrome of inappropriate ADH secretion (SIADH).<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">NaS: serum sodium; GS: glucose serum; TV: tolvaptan.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "David E. Barajas Galindo, Jorge Gabriel Ruiz-Sánchez, Alberto Fernández Martínez, Isabelle Runkle de la Vega, Juan Carlos Ferrer García, Guillermo Ropero-Luis, Ana Ortolá Buigues, Joaquín Serrano Gotarredona, Emilia Gómez Hoyos" "autores" => array:9 [ 0 => array:2 [ "nombre" => "David E." "apellidos" => "Barajas Galindo" ] 1 => array:2 [ "nombre" => "Jorge Gabriel" "apellidos" => "Ruiz-Sánchez" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Fernández Martínez" ] 3 => array:2 [ "nombre" => "Isabelle Runkle" "apellidos" => "de la Vega" ] 4 => array:2 [ "nombre" => "Juan Carlos" "apellidos" => "Ferrer García" ] 5 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Ropero-Luis" ] 6 => array:2 [ "nombre" => "Ana" "apellidos" => "Ortolá Buigues" ] 7 => array:2 [ "nombre" => "Joaquín" "apellidos" => "Serrano Gotarredona" ] 8 => array:2 [ "nombre" => "Emilia" "apellidos" => "Gómez Hoyos" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2530016422001045" "doi" => "10.1016/j.endinu.2022.01.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2530016422001045?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2530018022001640?idApp=UINPBA00004N" "url" => "/25300180/00000070000000S1/v2_202304211110/S2530018022001640/v2_202304211110/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Consensus document</span>" "titulo" => "Diabetes mellitus and pregnancy. Updated clinical practice guideline 2021. Executive summary" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "6" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria Goya, Merce Codina" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Maria" "apellidos" => "Goya" "email" => array:1 [ 0 => "mariagoya@mac.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Merce" "apellidos" => "Codina" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Endocrinología, Hospital Universitari Son Espases, Palma de Mallorca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diabetes mellitus y embarazo. Guía de práctica clínica actualizada 2021. Resumen ejecutivo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1519 "Ancho" => 2515 "Tamanyo" => 250279 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0130" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic strategy for gestational diabetes in pregnancy (two steps). OGTT: 100<span class="elsevierStyleHsp" style=""></span>g oral glucose tolerance test. * Optionally, a 50<span class="elsevierStyleHsp" style=""></span>g O’Sullivan test can be performed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus (DM) is the metabolic disorder most frequently associated with pregnancy. Approximately 1% of all pregnant women have pre-gestational DM (PGDM), and 12% or more, depending on the diagnostic strategy used, will have gestational diabetes mellitus (GDM). Of the women who have diabetes during pregnancy, it is estimated that approximately 87.5% have GDM, 7.5% have type 1 DM (DM1) and the remaining 5% have type 2 DM (DM2).</p><p id="par0010" class="elsevierStylePara elsevierViewall">In Spain, the prevalence of DM1, and especially that of DM2, has increased in recent years. Recent data shows that the incidence of GDM is also increasing as a result of higher rates of obesity and more pregnancies in older women.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This article focuses on areas where additional or different care should be offered to women with diabetes and their newborns, based on the available evidence (full practice guideline available at: <a href="https://www.sediabetes.org/grupos_de_trabajo/diabetes-y-embarazo/">https://www.sediabetes.org/grupos_de_trabajo/diabetes-y-embarazo/</a>; <a href="https://sego.es/Guias_de_Asistencia_Practica#perinatal">https://sego.es/Guias_de_Asistencia_Practica#perinatal</a>).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Classification of pregnancy-related diabetes</span><p id="par0020" class="elsevierStylePara elsevierViewall">All diabetes diagnosed before pregnancy is considered PGDM. Within this group, we can find DM1, DM2 and other specific types, such as monogenic diabetes. During pregnancy, it is important to rule out the presence of frank diabetes at the first antenatal visit, thus excluding the need for a diagnosis of GDM.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pre-gestational diabetes</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Preconception control</span><p id="par0025" class="elsevierStylePara elsevierViewall">Optimal glycaemic control in the periconceptional period and during pregnancy is associated with better maternal and fetal outcomes, including reduced risk of malformations and perinatal mortality. Therefore, all women of childbearing age with diabetes should receive regular preconception advice from the healthcare team that cares for them, whether in primary or specialised care (gynaecology/endocrinology). The risk for each patient wishing to become pregnant will be assessed individually and glycaemic control and treatment of associated complications and comorbidities will be optimised, suspending or replacing potentially teratogenic drugs with others that are safer for pregnancy.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Glycaemic control target:</span> HbA1c <6.5% (48<span class="elsevierStyleHsp" style=""></span>mmol/l), if it can be achieved with low risk of hypoglycaemia. In women with DM1, the use of continuous glucose monitoring and/or continuous subcutaneous insulin infusion may be considered.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Daily supplementation with folic acid</span> (at least 400<span class="elsevierStyleHsp" style=""></span>μg) <span class="elsevierStyleItalic">and iodine</span> (at least 200<span class="elsevierStyleHsp" style=""></span>μg).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Health education:</span> reducing weight in case of obesity and abandoning the consumption of tobacco and other toxins.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Contraception:</span> recommended until the right conditions for pregnancy are met.</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diabetes control during pregnancy</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Metabolic control</span><p id="par0050" class="elsevierStylePara elsevierViewall">The same goals are recommended as in the preconception period:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Basal blood glucose: 70–95<span class="elsevierStyleHsp" style=""></span>mg/dl (3.9–5.3<span class="elsevierStyleHsp" style=""></span>mmol/l).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Postprandial blood glucose (1<span class="elsevierStyleHsp" style=""></span>h): 110–140<span class="elsevierStyleHsp" style=""></span>mg/dl (6.1–7.8<span class="elsevierStyleHsp" style=""></span>mmol/l).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Postprandial blood glucose (2<span class="elsevierStyleHsp" style=""></span>h): 100–120<span class="elsevierStyleHsp" style=""></span>mg/dl (5.5–6.7<span class="elsevierStyleHsp" style=""></span>mmol/l).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Continuous glucose monitoring: time in range (63–140<span class="elsevierStyleHsp" style=""></span>mg/dl) >70%; time <63<span class="elsevierStyleHsp" style=""></span>mg/dl: <4%; time >140<span class="elsevierStyleHsp" style=""></span>mg/dl: <25%.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Mean HbA1c ±2 SD (4.8–5.7% or 29–38.8<span class="elsevierStyleHsp" style=""></span>mmol/l); <6.5% according to NICE; <6.5% in the first trimester, and <6.0% in the second and third, according to ADA.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Absence of ketonuria and hypoglycaemia.</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Treatment methods</span><p id="par0375" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Adapt the diet and recommend the practice of daily moderate physical exercise.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding treatment with oral hypoglycaemic agents, metformin may be justified in pregnant women with DM2 in conjunction with insulin, to avoid using large amounts of insulin.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding insulin treatment, a <span class="elsevierStyleItalic">basal-bolus</span> regimen or continuous insulin infuser can be used, preferably implemented in the preconception period. Be aware of changes in insulin sensitivity in relation to hormonal changes.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Home self-monitoring: three preprandial capillary blood glucose tests and three daily postprandial blood glucose tests are recommended in cases of blood glucose >200<span class="elsevierStyleHsp" style=""></span>mg/dl, with analysis of baseline ketonuria, to rule out ketosis/ketoacidosis.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Use <span class="elsevierStyleItalic">flash</span> or real-time continuous glucose monitoring whenever possible.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Provide glucagon to use in case of severe hypoglycaemia.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Measurement of HbA1c every 4–8 weeks.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">Joint follow-up by obstetrician and diabetologist every 2–4 weeks <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ophthalmological monitoring</span><p id="par0125" class="elsevierStylePara elsevierViewall">Pregnancy can cause progression of diabetic retinopathy, especially if it is severe. It is advisable to examine the fundus at least prior to pregnancy and at 28 weeks. If no previous examination has been done recently, do one also in the first trimester <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Nephrological monitoring</span><p id="par0130" class="elsevierStylePara elsevierViewall">Determination of albuminuria and creatinine is recommended every trimester. Suspend treatment with ACE inhibitors and ARBs, replacing them with others with less risk to the fetus (alpha-methyldopa, labetalol and calcium antagonists).</p><p id="par0135" class="elsevierStylePara elsevierViewall">Obstetric monitoring completion of pregnancy and mode of delivery</p><p id="par0140" class="elsevierStylePara elsevierViewall">It should be aimed at preventing pre-eclampsia and early diagnosis of a possible appearance of structural malformations, fetal cardiomyopathy and macrosomia.</p><p id="par0145" class="elsevierStylePara elsevierViewall">PGDM is a risk factor for pre-eclampsia, so screening in the first trimester is recommended. If screening is high risk, the ADA recommends starting with acetylsalicylic acid (ASA) at low doses of 60–150<span class="elsevierStyleHsp" style=""></span>mg/day. Although there is controversy about the optimal dose of ASA, since doses of 150<span class="elsevierStyleHsp" style=""></span>mg/day were used in the ASPRE study, there are several meta-analyses that have found a reduction in cases of pre-eclampsia with doses ≥100<span class="elsevierStyleHsp" style=""></span>mg/day, so we should recommend a dose of 100–150<span class="elsevierStyleHsp" style=""></span>mg/day from 12 weeks of gestation and up to 36<span class="elsevierStyleSup">+6</span> weeks. If screening is not available, preventive treatment with ASA is recommended in all pregnant women with diabetes.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Ultrasound control is recommended to monitor fetal growth, amniotic fluid volume and placental characteristics, which should be performed monthly from 28–30 weeks. It is recommended to perform an early echocardiography at week 14–16, especially in pregnant women with a higher risk of malformations (BMI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, unplanned pregnancy, HbA1c >8%, polyhydramnios, ketoacidosis, severe diabetic nephropathy), as well as another fetal echocardiography at week 28–32 for the study of hypertrophic cardiomyopathy, mainly in pregnant women with poor metabolic control.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Induction of labour at term is generally accepted to reduce the risk of complications. With correct metabolic control and adequate monitoring of fetal well-being, the pregnancy should be allowed to progress until the spontaneous onset of labour, with induction of labour appropriate from week 38<span class="elsevierStyleSup">+6</span>.When there are no guarantees of adequate follow-up, there is suboptimal glycaemic control or there are other maternal or fetal complications (maternal vasculopathy, worsening renal failure, active proliferative retinopathy, pre-eclampsia, IUGR), termination of the pregnancy from week 36<span class="elsevierStyleSup">+0</span> will be considered.</p><p id="par0160" class="elsevierStylePara elsevierViewall">If it is necessary to terminate pregnancy before week 34<span class="elsevierStyleSup">+6</span>, corticosteroids should be administered to accelerate fetal lung maturation, taking into account the corresponding adequacy of insulin treatment.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Atosiban and nifedipine are the drugs of choice for the treatment of threatened preterm labour. β-mimetics are not recommended due to their hyperglycaemic effect. The method of induction will depend on the cervical conditions. With a favourable cervix (Bishop index >6): amniotomy, cardiotocographic monitoring and oxytocin infusion; with an unfavourable cervix: prior cervical ripening with prostaglandins or with mechanical methods to reduce the risk of uterine hyperstimulation (fetal macrosomia or polyhydramnios).</p><p id="par0170" class="elsevierStylePara elsevierViewall">The route of choice for delivery will be vaginal. The indications for caesarean section are the same as for pregnant women without diabetes, except when the estimated fetal weight exceeds 4,500<span class="elsevierStyleHsp" style=""></span>g or there is a history of shoulder dystocia, in which case caesarean section is recommended in order to avoid obstetric trauma. Induction of labour should be avoided when fetal macrosomia is suspected, as this intervention has not been proven to improve maternal or fetal outcomes and may increase the rate of cesarean sections. There is no contraindication to attempting vaginal delivery in women with a history of previous cesarean section, although the rate of vaginal delivery appears to be lower than in women without diabetes.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Diabetic retinopathy is not a contraindication for vaginal delivery, although in the case of severe proliferative retinopathy it is recommended to shorten the expulsive period to avoid the development of retinal haemorrhages, and the use of locoregional anaesthesia during delivery is also recommended.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Intrapartum metabolic control</span><p id="par0180" class="elsevierStylePara elsevierViewall">Its objective is to avoid maternal metabolic complications and contribute to reducing neonatal morbidity. Neonatal hypoglycaemia is mostly related to intra-pregnancy control, but intrapartum hyperglycaemia (>140–180<span class="elsevierStyleHsp" style=""></span>mg/dl) also contributes.</p><p id="par0185" class="elsevierStylePara elsevierViewall">With little evidence from clinical trials, the following is recommended:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Control objective:</span> capillary blood glucose between 70–110<span class="elsevierStyleHsp" style=""></span>mg/dl (3.9–6.1<span class="elsevierStyleHsp" style=""></span>mmol/l), trying to minimise maternal hypoglycaemia.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Carbohydrate intake:</span> 5% dextrose serum at a rate of 125<span class="elsevierStyleHsp" style=""></span>ml/h (500 cc/4<span class="elsevierStyleHsp" style=""></span>h) to minimise ketogenesis.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">•</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Insulin intake:</span> administer fast-acting insulin, preferably by intravenous infusion, due to the flexibility that this route provides.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">•</span><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Monitoring:</span> hourly control of capillary blood glucose to adjust the rhythm of glucose and/or insulin infusions.</p></li></ul></p><p id="par0210" class="elsevierStylePara elsevierViewall">There are observational data that support the use of a subcutaneous insulin pump and continuous glucose monitoring as an alternative, provided that institutional protocols are available in this regard.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Breastfeeding and puerperium</span><p id="par0215" class="elsevierStylePara elsevierViewall">Newborn care differs from that established for pregnant women without diabetes in the need to prevent, detect and treat neonatal hypoglycaemia. After delivery, insulin treatment will be discontinued and glycaemic controls will be carried out to confirm the metabolic situation in the immediate postpartum period. Breastfeeding is recommended. The need to adjust insulin treatment and diet, the recommendations for other diabetes treatments in this period and the specific puerperal controls for each patient should be clarified.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Special considerations in women with diabetes and of childbearing age</span><p id="par0220" class="elsevierStylePara elsevierViewall">The indications and efficacy of the different contraceptive methods available are similar to those for the general population. Contraceptive methods that combine oestrogen and progestin have been shown to be safe in women with type 1 and 2 diabetes. However, in patients with vasculopathy, the potential risk of thrombotic phenomena must be taken into account and other options must be evaluated, such as methods that only use gestagens (pill, levonorgestrel IUD, subdermal implants) or copper IUD, since all of them are associated with a lower rate of thrombotic effects.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Gestational diabetes</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0225" class="elsevierStylePara elsevierViewall">There are two strategies for diagnosis:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">One-step strategy. With 75<span class="elsevierStyleHsp" style=""></span>g oral glucose tolerance test (OGTT).</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Two-step strategy. 50<span class="elsevierStyleHsp" style=""></span>g OGTT screening test and, if positive (≥140<span class="elsevierStyleHsp" style=""></span>mg/dl), 100<span class="elsevierStyleHsp" style=""></span>g OGTT diagnostic test.</p></li></ul></p><p id="par0240" class="elsevierStylePara elsevierViewall">The screening/diagnostic test will be carried out:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">first trimester</span> if there are risk factors for GDM.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">second trimester</span> (week 24–28 of gestation) in all pregnant women not previously diagnosed.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">third trimester</span> in those not previously studied and/or who develop complications (polyhydramnios, macrosomia).</p></li></ul></p><p id="par0260" class="elsevierStylePara elsevierViewall">The GEDE [Grupo Español de Diabetes y Embarazo (Spanish Diabetes and Pregnancy Group)] continues to recommend a two-step diagnosis and the use of the diagnostic criteria of the <span class="elsevierStyleItalic">National Diabetes Data Group</span> (NDDG) and the <span class="elsevierStyleItalic">3rd Workshop-Conference on Gestational Diabetes Mellitus</span> (two or more values equal to or greater than the following: basal blood glucose 105<span class="elsevierStyleHsp" style=""></span>mg/dl, 190<span class="elsevierStyleHsp" style=""></span>mg/dl at one hour, 165<span class="elsevierStyleHsp" style=""></span>mg/dl at two hours and 145<span class="elsevierStyleHsp" style=""></span>mg/dl at three hours), considering that there is insufficient evidence with randomised controlled trials that show benefits in terms of pregnancy outcomes with the diagnosis and treatment of GDM with the IADPSG criteria versus these previous criteria.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Control during pregnancy and childbirth</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Metabolic control</span><p id="par0265" class="elsevierStylePara elsevierViewall">Treatment begins with a diet plan, physical activity, weight control and blood glucose control to achieve the objectives:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">•</span><p id="par0270" class="elsevierStylePara elsevierViewall">Fasting blood glucose <95<span class="elsevierStyleHsp" style=""></span>mg/dl (5.3<span class="elsevierStyleHsp" style=""></span>mmol/l).</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0275" class="elsevierStylePara elsevierViewall">One-hour postprandial blood glucose <140<span class="elsevierStyleHsp" style=""></span>mg/dl (7.8<span class="elsevierStyleHsp" style=""></span>mmol/l) or two-hour postprandial glucose <120<span class="elsevierStyleHsp" style=""></span>mg/dl (6.7<span class="elsevierStyleHsp" style=""></span>mmol/l).</p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">Most GDM patients can control blood glucose levels with lifestyle modification.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Nutritional control and exercise</span><p id="par0285" class="elsevierStylePara elsevierViewall">Caloric needs will be similar to the rest of pregnant women, not recommending diets with fewer than 1,700<span class="elsevierStyleHsp" style=""></span>kcal and promoting weight gain in accordance with the recommendations of the Institute of Medicine (2009). A minimum intake of 175<span class="elsevierStyleHsp" style=""></span>g of carbohydrates is recommended, limiting fast-absorbing carbohydrates, which represents 40-50% of total calories, along with a fibre intake of 28<span class="elsevierStyleHsp" style=""></span>g per day. The diet should emphasise monounsaturated and polyunsaturated fats, limit saturated fats and avoid trans fats, recommending that they should contribute 30% to 40% of total calories. The minimum protein intake will be 71<span class="elsevierStyleHsp" style=""></span>g per day, based on weight.</p><p id="par0290" class="elsevierStylePara elsevierViewall">Aspartame, sucralose and stevia are considered safe non-caloric sweeteners, when consumed in moderation. The use of saccharin and cyclamate is not recommended. Daily physical exercise of 20–60<span class="elsevierStyleHsp" style=""></span>min three to four days a week is recommended.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Self-monitoring of capillary blood glucose</span><p id="par0295" class="elsevierStylePara elsevierViewall">In general, the recommendation is to carry out four capillary blood glucose checks per day: preprandial and postprandial at breakfast and preprandial and postprandial at lunch or dinner (every other day). In general, at diagnosis it will be recommended daily, modifying this frequency according to the results of the glycaemic profile. Carry out one or two weekly 6-point profiles, including pre-meal and pre-dinner blood glucose levels and control of ketonuria.</p><p id="par0300" class="elsevierStylePara elsevierViewall">If lifestyle modifications within one to two weeks do not achieve glycaemic control goals (two control levels above goals at the same time of day), or in the case of fetal overgrowth, pharmacological treatment may be necessary.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Pharmacological treatment</span><p id="par0305" class="elsevierStylePara elsevierViewall">Insulin is the first-line agent. Basal insulin will be used in the case of high fasting blood glucose levels in two or more controls, with the starting dose being 0.1–0.2<span class="elsevierStyleHsp" style=""></span>U/kg/day. For prandial insulin, 0.7–1.5<span class="elsevierStyleHsp" style=""></span>IU (obesity)/10<span class="elsevierStyleHsp" style=""></span>g of carbohydrates at breakfast and 0.5–1<span class="elsevierStyleHsp" style=""></span>IU (obesity)/10<span class="elsevierStyleHsp" style=""></span>g of carbohydrates at lunch and dinner could be an appropriate calculation. The insulin dose, both basal and prandial, will be adjusted according to the glycaemic control levels.</p><p id="par0310" class="elsevierStylePara elsevierViewall">Metformin can be considered the pharmacological alternative in patients with difficult follow-up or who refuse to take insulin.</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Obstetric control and termination of pregnancy</span><p id="par0315" class="elsevierStylePara elsevierViewall">Obstetric control will be similar to that carried out in normal pregnant women, with some clarification. Follow-up in patients with GDM will include the recommendation to perform an additional ultrasound scan at week 28–30 to detect polyhydramnios and fetal macrosomia. Ultrasound at around week 36–38 can provide useful information for planning the termination of pregnancy.</p><p id="par0320" class="elsevierStylePara elsevierViewall">Pregnant women with GDM associated with poor glycaemic control, macrosomia, obesity or the existence of other comorbidities are at risk of worse perinatal outcomes. The priority objective in this group will be to carry out stricter follow-up and control, until it is similar to pregnant women with PGDM in the most severe cases.</p><p id="par0325" class="elsevierStylePara elsevierViewall">Termination of pregnancy in patients with well-controlled GDM will be similar to in the general population. However, in patients with risk factors, such as those who require insulin, the decision will be individualised, although prolonging gestation beyond 39–40 weeks is generally not recommended.</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Intrapartum monitoring</span><p id="par0330" class="elsevierStylePara elsevierViewall">In cases that require insulin, or in those with macrosomia, the same metabolic targets should be maintained as in PGDM, so capillary blood glucose should be monitored (target 70–110<span class="elsevierStyleHsp" style=""></span>mg/dl, without ketonuria) Insulin treatment will preferably be by continuous intravenous infusion, supplying glucose at 5–10% and performing hourly monitoring of capillary blood glucose to adjust the rate of infusion.</p><p id="par0335" class="elsevierStylePara elsevierViewall">Newborn care differs from that established for pregnant women without diabetes in the need to prevent, detect and treat neonatal hypoglycaemia. After delivery, insulin treatment will be discontinued and glycaemic controls will be carried out to confirm the metabolic situation in the immediate postpartum period.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Postpartum follow-up</span><p id="par0340" class="elsevierStylePara elsevierViewall">GDM identifies a group of women with a higher risk of developing diabetes mellitus, metabolic syndrome and cardiovascular disease throughout their lives. The evaluation of hydrocarbon metabolism will be carried out using a 75<span class="elsevierStyleHsp" style=""></span>g OGTT, preferably between 6–12 weeks postpartum, although this period could be extended up to six months or after the end of lactation. A fasting glycaemia prior to discharge ≥100<span class="elsevierStyleHsp" style=""></span>mg/dl allows us to identify those patients with a higher risk of persistent diabetes and who would benefit from earlier intervention.</p><p id="par0345" class="elsevierStylePara elsevierViewall">There is no validated strategy for long-term follow-up after the first reassessment, although an annual metabolic review is recommended in cases of categories of increased risk of diabetes, and one every three years in case of normal tolerance to glucose, while other components of the metabolic syndrome should also be evaluated.</p><p id="par0350" class="elsevierStylePara elsevierViewall">Breastfeeding should be recommended and encouraged due to its beneficial effects on the mother and the baby. Interventions aimed at optimising diet and lifestyle have been shown to be cost-effective in this group of patients, especially if they are started during pregnancy. The recommendations regarding contraception are similar to those for the general population.</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Justification of diabetes and pregnancy clinics (DPCs)</span><p id="par0355" class="elsevierStylePara elsevierViewall">Multidisciplinary teams, made up primarily of obstetricians, endocrinologists/diabetologists and diabetes educators/dieticians, have been shown to improve glycaemic control and maternal-fetal outcomes in women with PGDM. Regarding the management of women with GDM, there is no uniform position in most of the guides on the role of DPCs, but there is uniformity in recommending the skills that are needed for their management, especially in nutritional treatment.</p><p id="par0360" class="elsevierStylePara elsevierViewall">Adequate management and follow-up of pregnant women with PGDM and GDM requires specialised units that can handle two levels of care complexity, as well as adequate coordination to enable early referral of patients between them.<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">•</span><p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Level A (outpatient primary and specialised care):</span> will basically carry out the diagnosis of GDM, its follow-up if it is controlled with diet and exercise, and postpartum control and follow-up.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">•</span><p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Level B (referral hospital):</span> will carry out, above all, the management of PGDM and its preconception planning, as well as the management of GDM that is difficult to control or requires drugs.</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Classification of pregnancy-related diabetes" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Pre-gestational diabetes" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Preconception control" ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "Diabetes control during pregnancy" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Metabolic control" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Treatment methods" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Ophthalmological monitoring" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Nephrological monitoring" ] ] ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Intrapartum metabolic control" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Breastfeeding and puerperium" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Special considerations in women with diabetes and of childbearing age" ] ] ] 3 => array:3 [ "identificador" => "sec0065" "titulo" => "Gestational diabetes" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Diagnosis" ] 1 => array:3 [ "identificador" => "sec0075" "titulo" => "Control during pregnancy and childbirth" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Metabolic control" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Nutritional control and exercise" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Self-monitoring of capillary blood glucose" ] 3 => array:2 [ "identificador" => "sec0095" "titulo" => "Pharmacological treatment" ] ] ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Obstetric control and termination of pregnancy" ] 3 => array:2 [ "identificador" => "sec0105" "titulo" => "Intrapartum monitoring" ] 4 => array:2 [ "identificador" => "sec0110" "titulo" => "Postpartum follow-up" ] ] ] 4 => array:2 [ "identificador" => "sec0115" "titulo" => "Justification of diabetes and pregnancy clinics (DPCs)" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-12-16" "fechaAceptado" => "2021-12-24" "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1519 "Ancho" => 2515 "Tamanyo" => 250279 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0130" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic strategy for gestational diabetes in pregnancy (two steps). OGTT: 100<span class="elsevierStyleHsp" style=""></span>g oral glucose tolerance test. * Optionally, a 50<span class="elsevierStyleHsp" style=""></span>g O’Sullivan test can be performed.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0135" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">OGTT: oral glucose tolerance test; ADA: American Diabetes Association; IADPSG: International Association of Diabetes and Pregnancy Study Groups; WHO: World Health Organization.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fasting plasma glucose \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">≥126<span class="elsevierStyleHsp" style=""></span>mg/dl<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> (7.0<span class="elsevierStyleHsp" style=""></span>mmol/l) on more than two occasions (IADPSG, WHO, ADA) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glucose 2<span class="elsevierStyleHsp" style=""></span>h after 75<span class="elsevierStyleHsp" style=""></span>g OGTT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥200<span class="elsevierStyleHsp" style=""></span>mg/dl<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> (11.1<span class="elsevierStyleHsp" style=""></span>mmol/l) (WHO, ADA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical symptomatology of diabetes and random glucose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥200<span class="elsevierStyleHsp" style=""></span>mg/dl<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> (11.1<span class="elsevierStyleHsp" style=""></span>mmol/l) (IADPSG, WHO, ADA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HbA<span class="elsevierStyleInf">1</span>c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥6.5%<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> (47.5<span class="elsevierStyleHsp" style=""></span>mmol/mol) (IADPSG, ADA) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In the absence of symptoms of hyperglycaemia, diagnosis outside of pregnancy requires two abnormal results of the same test or two separate tests. This requirement is obviated in pregnancy.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Diagnosis of frank diabetes from random blood glucose ≥200<span class="elsevierStyleHsp" style=""></span>mg/dl requires confirmation, either clinical symptoms of diabetes, basal blood glucose or plasma glucose at 2<span class="elsevierStyleHsp" style=""></span>h of OGTT.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagnostic criteria for frank diabetes during pregnancy.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0140" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">When? \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">In whom? \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">How? \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Where? \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1st trimester (at 10–12 weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High-risk pregnant women (recommendation B): Age ≥35 years Obesity (BMI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>30) Personal history of GDM, or poor obstetric history (macrosomia or polyhydramnios) Family history of DM in first-degree relatives Ethnic minorities with a high prevalence of DM (pregnant women from Latin America, from Southeast Asia, …) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">O’Sullivan test (50<span class="elsevierStyleHsp" style=""></span>g OGTT) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At the health centre \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2nd trimester (at 24–28 weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UNIVERSAL (recommendation A) For all pregnant women not previously diagnosed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3rd trimester \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications associated with GDM (macrosomia or hydramnios) in pregnant women not previously diagnosed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100<span class="elsevierStyleHsp" style=""></span>g OGTT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usually in hospital \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Indications for gestational diabetes screening.</p>" ] ] ] ] "idiomaDefecto" => "en" "url" => "/25300180/00000070000000S1/v2_202304211110/S2530018022001639/v2_202304211110/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/25300180/00000070000000S1/v2_202304211110/S2530018022001639/v2_202304211110/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2530018022001639?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 30 | 9 | 39 |
| 2024 October | 232 | 44 | 276 |
| 2024 September | 290 | 45 | 335 |
| 2024 August | 227 | 31 | 258 |
| 2024 July | 243 | 31 | 274 |
| 2024 June | 193 | 10 | 203 |
| 2024 May | 215 | 25 | 240 |
| 2024 April | 205 | 40 | 245 |
| 2024 March | 239 | 46 | 285 |
| 2024 February | 261 | 32 | 293 |
| 2024 January | 163 | 18 | 181 |
| 2023 December | 59 | 14 | 73 |
| 2023 November | 34 | 7 | 41 |
| 2023 October | 23 | 5 | 28 |
| 2023 September | 10 | 2 | 12 |
| 2023 August | 1 | 0 | 1 |
Show all
