Información del artículo
La prevalencia de diabetes mellitus tipo 2 (DM2) en la gestación está en aumento y puede superar la de la diabetes mellitus tipo 1 (DM1). En general, el tratamiento es similar, con algunas particularidades. Las pacientes con DM2 son de mayor edad, son más obesas, tienen hipertensión crónica con mayor frecuencia, reciben asistencia pregestacional específica con menor frecuencia, consultan más tarde durante la gestación y están más expuestas a fármacos potencialmente teratógenos. En contrapartida, el tiempo de evolución de la enfermedad y la frecuencia de complicaciones son inferiores y el control metabólico es mejor. Aunque hay controversia, la evolución perinatal es similar, a excepción de la prematuridad, que es inferior en DM2.
El fármaco recomendado para el tratamiento de la hiperglucemia es la insulina. Antes del embarazo, el énfasis debe ponerse en aumentar la asistencia pregestacional, mejorar el control glucémico, reforzando la educación diabetológica, y evitar la exposición a fármacos potencialmente teratógenos. Durante la gestación, los últimos objetivos continúan vigentes. Después del parto, se debe replantear el programa terapéutico teniendo en cuenta el paso de los fármacos a la leche materna.
Palabras clave:
Diabetes mellitus tipo 2
Gestación
Mortalidad perinatal
Malformaciones
Necesidades de insulina
The prevalence of type 2 diabetes mellitus (DM2) in pregnancy is increasing and can exceed that of type 1 DM (DM1). In general, treatment is similar with some special considerations. Patients with DM2 are older and heavier, more likely to have chronic hypertension, less likely to receive specific prepregnancy care, consult later in pregnancy, and are more frequently exposed to potentially teratogenic drugs. In contrast, diabetes duration and the complications rate are lower and metabolic control is better. Although there is some controversy on the topic, perinatal outcomes are similar, except for the prematurity rate, which is lower in DM2. The recommended drug for the treatment of hyperglycemia is insulin. Before pregnancy, emphasis should be placed on increasing attendance at prepregnancy care, improving glycemic control, reinforcing diabetes instruction and avoiding exposure to potentially teratogenic drugs. During pregnancy, the latter aims remain applicable. After delivery, the treatment regimen should be reconsidered, taking into account transfer of different drugs through breast milk.
Key words:
Type 2 diabetes mellitus
Pregnancy
Perinatal mortality
Congenital malformations
Insulin requirements
El Texto completo está disponible en PDF
Bibliografía
[1.]
P.M. Catalano, J.P. Kirwan.
Clinical utility and approaches for estimating insulin sensitivity in pregnancy.
Semin Perinatol, 26 (2002), pp. 181-189
[2.]
A. Goday.
Epidemiology of diabetes and its non-coronary complications.
Rev Esp Cardiol, 55 (2002), pp. 657-670
[3.]
L. Serra-Majem, J. Aranceta Bartrina, C. Pérez-Rodrigo, L. Ribas-Barba, A. Delgado-Rubio.
Prevalence and deteminants of obesity in Spanish children and young people.
Br J Nutr, 96 (2006), pp. S67-72
[4.]
J.L. Kitzmiller, T.A. Buchanan, S. Kjos, C.A. Combs, R.E. Ratner.
Pre-conception care of diabetes, congenital malformations, and spontaneous abortions.
Diabetes Care, 19 (1996), pp. 514-541
[5.]
M.L. Martínez-Frías.
Epidemiological analysis of outcomes of pregnancy in diabetic mothers: identification of the most characteristic and most frequent congenital anomalies.
Am J Med Genet, 51 (1994), pp. 108-113
[6.]
J.G. Ray, T.E. O’Brien, W.S. Chan.
Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis.
Q J Med, 94 (2001), pp. 435-444
[7.]
J.M. Roland, H.R. Murphy, V. Ball, J. Northcote-Wright, R.C. Temple.
The pregnancies of women with type 2 diabetes: poor outcomes but opportunities for improvement.
Diabetes Med, 22 (2005), pp. 1774-1777
[8.]
T.D. Clausen, E. Mathiesen, P. Ekbom, E. Hellmuth, T. Mandrup-Poulsen, P. Damm.
Poor pregnancy outcome in women with type 2 diabetes.
Diabetes Care, 28 (2005), pp. 323-328
[9.]
American Diabetes Association.
Preconception care of women with diabetes.
Diabetes Care, 27 (2004), pp. S76-S79
[10.]
W. Ricart, J. López, J. Mozas, A. Pericot, M.A. Sancho, N. González, et al.
Body mass index has a greater impact on pregnancy outcomes than gestational hyperglycaemia.
Diabetologia, 48 (2005), pp. 1736-1742
[11.]
M.L. Watkins, S.A. Rasmussen, M.A. Honein, L.D. Botto, C.A. Moore.
Maternal obesity and risk for birth defects.
Pediatrics, 111 (2003), pp. 1152-1158
[12.]
L.L. Moore, M.R. Singer, M.L. Bradlee, K.J. Rothman, A. Milunsky.
A prospective study of the risk of congenital defects associated with maternal obesity and diabetes mellitus.
Epidemiology, 11 (2000), pp. 689-694
[13.]
C. Gilbert, M. Valois, G. Koren.
Pregnancy outcome after first-trimester exposure to metformin: a meta-analysis.
Fertil Steril, 86 (2006), pp. 658-663
[14.]
D.J. Jakubowicz, M.J. Iuorno, S. Jakubowicz, C.A. Roberts, J.E. Nestler.
Effects of metformin on early pregnancy loss in the polycystic ovary syndrome.
J Clin Endocrinol Metab, 82 (2002), pp. 542-549
[15.]
K. Piacquadio, D.R. Hollingsworth, H. Murphy.
Effects of in-utero exposure to oral hypoglycaemic drugs.
Lancet, 338 (1991), pp. 866-869
[16.]
D. Towner, S.L. Kjos, B. Leung, M.M. Montoro, A. Xiang, J.H. Mestman, et al.
Congenital malformations in pregnancies complicated by NIDDM.
Diabetes Care, 18 (1995), pp. 1446-1451
[17.]
L.Y. Chan, J.H. Yeung, T.K. Lau.
Placental transfer of rosiglitazone in the first trimester of human pregnancy.
Fertil Steril, 83 (2005), pp. 955-958
[18.]
H.J. Holmes, B.M. Casey, R.E. Bawdon.
Placental transfer of rosiglitazone in the ex vivo human perfusion model.
Am J Obstet Gynecol, 195 (2006), pp. 1715-1719
[19.]
D. Simmons, C.F. Thompson, C. Conroy, D.J. Scott.
Use of insulin pumps in pregnancies complicated by type 2 diabetes and gestational diabetes in a multiethnic community.
Diabetes Care, 24 (2001),
[20.]
R. Corcoy.
Evidencias actuales sobre el uso de análogos de insulina en la gestación diabética.
Av Diabetol, 21 (2005), pp. 198-205
[21.]
De Leiva A, García-Patterson A, Sojo L, Ubeda J, Erdozain L, Prados A, et al. Similar outcome in pregnancies from type 1 and type 2 diabetic patients. Pp 08, 37th Annual DPSG Meeting, Myconos, Hellas, 15-18 September 2005.
[22.]
R.J. Edison, M. Muenke.
Central nervous system and limb anomalies in case reports of first-trimester statin exposure.
N Engl J Med, 350 (2004), pp. 1579-1582
[23.]
P.S. Pollack, K.E. Shields, D.M. Burnett, M.J. Osborne, M.L. Cunningham, M.E. Stepanavage.
Pregnancy outcomes after maternal exposure to simvastatin and lovastatin.
Birth Defects Res A Clin Mol Teratol, 73 (2005), pp. 888-896
[24.]
R.J. Edison, M. Muenke.
Mechanistic and epidemiologic considerations in the evaluation of adverse birth outcomes following gestational exposure to statins.
Am J Med Genet A, 131 (2004), pp. 287-298
[25.]
P.F. Plouin, C. Tchobroutsky.
Inhibition of angiotensin converting enzyme in human pregnancy. 15 cases.
Presse Med, 14 (1985), pp. 2175-2178
[26.]
H. Saji, M. Yamanaka, A. Hagiwara, R. Ijiri.
Losartan and fetal toxic effects.
Lancet, 357 (2001), pp. 363
[27.]
Centers for Disease Control and Prevention.
Postmarketing surveillance for angiotensin-converting enzyme inhibitor use during the first trimester of pregnancy-United States, Canada, and Israel, 1987-1995.
JAMA, 277 (1997), pp. 1193-1194
[28.]
W.O. Cooper, S. Hernández-Díaz, P.G. Arbogast, J.A. Dudley, S. Dyer, P.S. Gideon, et al.
Major congenital malformations after first-trimester exposure to ACE inhibitors.
N Engl J Med, 354 (2006), pp. 2443-2451
[29.]
F. Hu, P. Morrissey, J. Yao, Z. Xu.
Development of AT(1) and AT(2) receptors in the ovine fetal brain.
Brain Res Dev Brain Res, 150 (2004), pp. 51-61
[30.]
P.R. James, C. Nelson-Piercy.
Management of hipertension before, during and after pregnancy.
Heart, 90 (2004), pp. 1499-1504
[31.]
American College of Obstetricians and Gynecologists Practice Bulletin Number 44.
Clinical management guidelines for obstetrician-gynecologists. Neural tube defects.
Obstet Gynecol, 102 (2003), pp. 203-213
[32.]
Grupo Español de Diabetes y Embarazo.
Diabetes y embarazo. Guía asistencial (3.ª edición).
Av Diabetol, 22 (2006), pp. 73-87
[33.]
Y.I. Kim.
Will mandatory folic acid fortification prevent or promote cancer?.
Am J Clin Nutr, 80 (2004), pp. 1123-1128
[34.]
G. Morreale de Escobar, M.J. Obregón, F.E. Del Rey.
Maternal thyroid hormones early in pregnancy and fetal brain development.
Best Pract Res Clin Endocrinol Metab, 18 (2004), pp. 225-248
[35.]
M. Zimmermann, F. Delange.
Iodine supplementation of pregnant women in Europe: a review and recommendations.
Eur J Clin Nutr, 58 (2004), pp. 979-984
[36.]
O. Langer, A. Anyaegbunam, L. Brustman, D. Guidetti, J. Levy, R. Mazze.
Pregestational diabetes: insulin requirements throughout pregnancy.
Am J Obstet Gynecol, 159 (1988), pp. 616-621
[37.]
N. Hillman, L. Herranz, P.M. Vaquero, A. Villarroel, A. Fernández, L.F. Pallardo.
Is pregnancy outcome worse in type 2 than in type 1 diabetic women?.
Diabetes Care, 29 (2006), pp. 2557-2558
[38.]
O. Langer, D.L. Conway, M.D. Berkus, E.M. Xenakis, O. Gonzales.
A comparison of glyburide and insulin in women with gestational diabetes mellitus.
N Engl J Med, 343 (2000), pp. 1134-1138
[39.]
G.F. Jacobson, G.A. Ramos, J.Y. Ching, R.S. Kirby, A. Ferrara, D.R. Field.
Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization.
Am J Obstet Gynecol, 193 (2005), pp. 118-124
[40.]
R.C.E. Hughes, J.A. Rowan.
Pregnancy in women with type 2 diabetes: who takes metformin and what is the outcome?.
Diabet Med, 23 (2006), pp. 318-322
[41.]
E. Hellmuth, P. Damm, L. Molsted-Pedersen.
Oral hypoglycaemic agents in 118 diabetic pregnancies.
Diabet Med, 17 (2000), pp. 507-511
[42.]
W.M. Hague, P.M. Davoren, H.D. McIntyre, R. Norris, X. Xiaonian, B. Charles.
Metformin crosses the placenta: a modulator for fetal insulin resistance?.
BMJ, 326 (2003), pp. 762
[43.]
A.L. Fowden, D.A. Giussani, A.J. Forhead.
Endocrine and metabolic programming during intrauterine development.
Early Hum Dev, 81 (2005), pp. 723-734
[44.]
F.M. Brown, J. Wyckoff, J.A. Rowan, L. Jovanovic, D.A. Sacks, G.G. Briggs.
Metformin in pregnancy: its time has not yet come.
Diabetes Care, 29 (2006), pp. 485-486
[45.]
D. Simmons, B.N. Walters, J.A. Rowan, H.D. McIntyre.
Metformin therapy and diabetes in pregnancy.
Med J Aust, 180 (2004), pp. 462-464
[46.]
A. McElduff, N.W. Cheung, H.D. McIntyre, J.A. Lagstrom, J.J. Oats, G.P. Ross, et al.
The Australasian Diabetes in Pregnancy Society consensus guidelines for the management of type 1 and type 2 diabetes in relation to pregnancy.
Med J Aust, 183 (2005), pp. 373-377
[47.]
D. Reader, M.J. Franz.
Lactation, diabetes, and nutrition recommendations.
Curr Diab Rep, 4 (2004), pp. 370-376
[48.]
American Academy of Pediatrics Committee on Drugs.
Transfer of drugs and other chemicals into human milk.
Pediatrics, 108 (2001), pp. 776-789
[49.]
World Health Organization/ UNICEF. Breastfeeding and maternal medication. Recommendations for Drugs in the Eleventh WHO Model List of Essential Drugs. 2003. Disponible en: www.who.int/child-adolescent health/New_Publications/NUTRITION/BF_Maternal_Medication.pdf
[50.]
T. Hale, L. Kristensen, R. Hackett, K. Kohan, K. Klett.
Transfer of metformin into human milk.
Diabetologia, 45 (2002), pp. 1509-1514
[51.]
C.J. Glueck, M. Salehi, L. Sieve, P. Wang.
Growth, motor, and social development in breast- and formula-fed infants of metformin-treated women with polycystic ovary syndrome.
J Pediatr, 148 (2006), pp. 628-632
[52.]
D.S. Feig, G.G. Briggs, J.M. Kraemer, P.J. Ambrose, D.N. Moskovitz, M. Nageotte, et al.
Transfer of glyburide and glipizide into breast milk.
Diabetes Care, 28 (2005), pp. 1851-1855
[53.]
J.W. Henk, W.R. Craft, A. Black, J. Colgin, J.A. Anderson.
Pre- and postnatal toxicity of the HMG-CoA reductase inhibitor atorvastatin in rats.
Toxicol Sci, 41 (1998), pp. 88-99
[54.]
D.A. Sacks, W. Chenn, J.S. Greenspoon, G. Wolde-Tsadikg.
Should the same glucose values be targeted for type 1 as for type 2 diabetics in pregnancy?.
Am J Obstet Gynecol, 177 (1997), pp. 1113-1119
[55.]
T. Cundy, G. Gamble, K. Townend, P.G. Henley, P. MacPherson, A.B. Roberts.
Perinatal mortality in type 2 diabetes mellitus.
Diabet Med, 17 (2000), pp. 33-39
[56.]
M.C. Macintosh, K.M. Fleming, J.A. Bailey, P. Doyle, J. Modder, D. Acolet, et al.
Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study.
BMJ, 333 (2006), pp. 177
[57.]
F. Dunne, P. Brydon, K. Smith, H. Gee.
Pregnancy in women with type 2 diabetes: 12 years outcome data 1990-2002.
Diabet Med, 20 (2003), pp. 734-738
Copyright © 2008. Sociedad Española de Endocrinología y Nutrición
