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Diabetes e gravidez : via e timing do parto
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A presença de hiperglicemia durante a gravidez leva a hiperglicemia fetal e consequentemente hiperinsulinismo fetal, que condiciona um maior risco de macrossomia fetal. Nas grávidas com diabetes o risco de distócia de ombros nos fetos macrossómicos é superior comparativamente com a população não diabética.
Adicionalmente regista-se também um maior risco de morte perinatal, malformações e parto pré-termo.
Estas complicações são elementos chave no que toca à determinação da altura e via de parto. Numa tentativa de reduzi-las, sem aumentar as morbilidades neonatais, tem sido programado o parto antes de atingir as 41 semanas.
No caso da diabetes prévia, devido a uma maior probabilidade de complicações, as 39 semanas de gestação, mesmo sob bom controlo glicémico, parecem ser o limite aceite pela maioria da comunidade científica. Pelo contrário, na diabetes gestacional este limite é bastante mais discutido. A maioria das recomendações permite uma atitude expectante até às 40+6 semanas quando existe um bom controlo glicémico, mas discute-se se não existirá benefício, também nestes casos, de um parto perto das 39 semanas.
Relativamente à via do parto, aquela que deverá ser preferida é a via vaginal. No entanto existem situações em que se preconiza a realização de uma cesariana. A macrossomia fetal é um diagnóstico que é universalmente aceite como indicado para CS, contudo o peso fetal a partir do qual deve ser recomendado é variável.
The presence of hyperglycemia during pregnancy leads to fetal hyperglycemia and consequently to fetal hyperinsulinism, which increases the risk of fetal macrosomia. In pregnant women with diabetes, the risk of shoulder dystocia in the macrosomic fetus is higher when compared to the non-diabetic population. In addition, there is a higher risk of perinatal death, malformations and preterm birth. These complications are key elements in determining the timing and mode of delivery. In an attempt to reduce them, without increasing neonatal morbidity, delivery has been scheduled before reaching 41 weeks of gesation. In pregnancies with prior diabetes, due to a greater risk of complications, 39 weeks of gestation, even under good glycemic control, seems to be the limit accepted by most of the scientific community. On the contrary, in gestational diabetes, this limit is much more debated. Most recommendations allow an expectant attitude up to 40 + 6 weeks when there is a good glycemic control, but it is discussed whether it would be beneficial, even in these cases, timing the delivery to 39 weeks. Regarding the way of delivering in most cases it is preferred the vaginal delivery. However, there are situations in which a cesarean section is recommended. Fetal macrosomia is a diagnosis that is universally accepted as indicated for CS, however the fetal weight from which it should be recommended is variable.
The presence of hyperglycemia during pregnancy leads to fetal hyperglycemia and consequently to fetal hyperinsulinism, which increases the risk of fetal macrosomia. In pregnant women with diabetes, the risk of shoulder dystocia in the macrosomic fetus is higher when compared to the non-diabetic population. In addition, there is a higher risk of perinatal death, malformations and preterm birth. These complications are key elements in determining the timing and mode of delivery. In an attempt to reduce them, without increasing neonatal morbidity, delivery has been scheduled before reaching 41 weeks of gesation. In pregnancies with prior diabetes, due to a greater risk of complications, 39 weeks of gestation, even under good glycemic control, seems to be the limit accepted by most of the scientific community. On the contrary, in gestational diabetes, this limit is much more debated. Most recommendations allow an expectant attitude up to 40 + 6 weeks when there is a good glycemic control, but it is discussed whether it would be beneficial, even in these cases, timing the delivery to 39 weeks. Regarding the way of delivering in most cases it is preferred the vaginal delivery. However, there are situations in which a cesarean section is recommended. Fetal macrosomia is a diagnosis that is universally accepted as indicated for CS, however the fetal weight from which it should be recommended is variable.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2019
Palavras-chave
Gravidez complicada por diabetes Macrossomia Distócia de ombros Indução do trabalho de parto Obstetrícia