BackgroundIn August 2011, the Specialized Center for Diabetes and Pregnancy of the Botucatu Medical School/Unesp adopted a new diagnostic protocol for gestational diabetes mellitus, recommended by the American Diabetes Association and the International Association of the Diabetes and Pregnancy Study Group. The glycemic profile was evaluated using the 75-g oral glucose tolerance test (OGTT) used to diagnose mild gestational hyperglycemia, recognized and treated in our department as gestational diabetes mellitus. The cost-effectiveness of the new guidelines and the continued need for the evaluation of the glycemic profile, as part of our Service protocol, are controversial and require further investigation. We aimed to assess the impact of the new guidelines on the evaluation of mild gestational hyperglycemia and gestational diabetes mellitus, the incidence of adverse perinatal outcomes, and the association between the 75-g OGTT and the glycemic profile for the diagnosis of mild gestational hyperglycemia.MethodsThis cross-sectional study was performed identifying a convenience sample of pregnant women and their newborns. The women used our Service for diagnostic procedures, prenatal care and delivery, both before (January 2008 to August 14, 2011) and after (August 15, 2011 to December 2014) the protocol modification. The following variables were compared, following stratification according to diagnostic protocol: prevalence of gestational diabetes mellitus and mild gestational hyperglycemia, newborns large for gestational age, macrosomia, first cesarean delivery, and newborn hospital stay. Statistical analysis was performed using Poisson regression, the Student’s t test, the Chi square or Fisher’s exact test and risk estimate. The statistical significance threshold was set at 95% (p < 0.05).ResultsThe new protocol resulted in an 85% increase in the number of women with GDM, but failed to identify 17.3% of pregnant women classified as having mild gestational hyperglycemia, despite a normal 75-g OGTT. The new guidelines did not affect perinatal outcome.ConclusionsThese results support the validity of maintaining the glycemic profile as part of the diagnostic protocol at our hospital. Large multicenter studies with an adequate sample size are required for conclusive evidence on the cost-effectiveness of the new protocol.

Introduction: Thrombophilias are associated with venous thromboembolism. According to reports, uteroplacental thrombosis can lead to preeclampsia, intrauterine growth restriction (IUGR), placental abruption (PA) and even to fetal death. The Brazilian Ministry of Health recommends the application of heparin treatment-associated, or not, with ASA to pregnant women diagnosed with thrombophilia, based on its type. However, many studies have not been able to confirm the beneficial effects of heparin use on maternal and fetal health. Methods: The current research is a case-control study comprising pregnant women treated at the Obstetrics Service of Federal University of Juiz de Fora and at the Medical School of Barbacena, who used heparin in the current pregnancy due to previously diagnosed thrombophilia. Current pregnancy associated with heparin use was named 'case', whereas previous pregnancy without heparin use was named 'control'. Thus, 47 cases (current pregnancy) and 32 controls were selected (1,4 cases: 1,0 control). Results: Association between heparin and miscarriage, intrauterine fetal death and preeclampsia were analyzed. Results showed that heparin acted as protective factor against miscarriage (OR=0.04; CI=0.01-0.14; p<0.0001), intrauterine fetal death (OR=0.01; CI=0.01-0.11; but heparin use did not reduce the frequency of preeclampsia cases (OR=0.35; CI=0.07-1.6; p=0.17). Conclusion: Based on the current results, the early heparin application to pregnant women with thrombophilia was able to reduce the number of miscarriage, intrauterine death, but did not reduce the frequency of preeclampsia.

Introduction: Doppler flowmetry of uterine arteries allows identifying women at risk of developing preeclampsia (PE), mainly early preeclampsia; it also facilitates the timely use of prophylaxis. Minidose Acetylsalicylic Acid (ASA) can help preventing/delaying preeclampsia development, as well as reducing its severity and the risk of complications. However, not all patients can use this medication; therefore, it is necessary finding clinical alternatives for pregnant women who do not tolerate ASA, as well as evaluating the possibility of increasing this prophylaxis with new drugsthe use of omega 3 is one of these alternatives. Thus, it is possible assuming that omega use by pregnant women could reduce the vascular resistance of uterine arteries and facilitate placentation. The aim of the current study is to evaluate uterine artery resistance and pulsatility indices, as well as bilateral notch in pregnant women presenting identifiable risk factor for PE development, who use omega 3 in association, or not, with ASA. Methodology: The current research is a randomized-controlled, non-blind, parallel, two-arm, open-label preventive clinical trial. Patients were divided into two groups: group 1-use of ASA; and group 2-use of ASA+omega 3. Omegabased supplementations comprised doses of 400 mg/day in gelatin capsules, at DHA: EPA ratios 2.5:1 and 5.0:1. Results: Patients' mean age was 33.48+4.68 years. Mean pregnancies and childbirths were 1.93+1.30 and 0.59 ± 0.37, respectively. Results of uterine artery Doppler flowmetry were associated with omega and/or ASA use; patients who used ASA in association with omega (ASA+omega) recorded the highest uterine artery resistance and pulsatility indices-results were statistically significant. The comparison between ASA use in association, or not, with omega did not show difference in PE, prematurity, oligohydramnios, IUGR or hospitalization in neonatal ICU frequency. There were no cases of fetal death or Hellp Syndrome in either groups. Conclusion: The omega 3 use in association with ASA has increased the uterine artery resistance and pulsatility indices of the investigated patients; however, it did not make any difference in primary and secondary outcomes.

Introduction: It is possible assuming that thrombophilias can change the optimal placental function, as well as lead to infarctions, impaired maternal-fetal exchange mechanisms and even to fetal death. Placental hypoxia determines a vicious cycle comprising oxidative stress, vasoconstriction and impaired fetal oxygenation. Prophylactic heparin use throughout pregnancy has been recommended in some thrombophilia cases because it acts on the coagulation cascade. However, although heparin does not cross the placental barrier and is safe for the fetus, not all patients can use it. Its administration route (parenteral) is not practical and even its prophylactic use is not necessarily harmless, as seen in different thrombocytopenia, gastrointestinal and cerebral bleeding reports. Thus, finding clinical alternatives for these pregnant women would help significantly improving the current medical practice. The use of essential fatty acids (EFAs) is a new perspective that appears to be applicable in daily medical practice, because it facilitates the blood flow and tissue oxygenation, since they reduce vascular resistance and platelet aggregation. Methods: This study is a randomized, controlled, unblind, parallel, three-arm, open-label prevention trial conducted with pregnant women diagnosed with thrombophilia, who were treated in the Obstetrics Services of University Hospitals belonging to UFJF and to Medical School of Barbacena. All the patients were divided in two groups: Group 1=Hereditary thrombophilia patients who used 40 mg of heparin/day (enoxaparin) from the 6th pregnancy week on; Group 2 Patients with acquired or hereditary thrombophilias associated with risk factors for preeclampsia, according to ACOG19 (chronic kidney disease, previous diabetes mellitus, chronic arterial hypertension and collagenoses). Results: The current study assessed 38 pregnant women. Patients' mean age was 32.9 ± 5.0 years. The pulsatility index in the second gestational trimester (24 to 28 weeks) was compared based on treatments. Patients treated with the H+ASA+omega association recorded the lowest pulsatility index; however, there was not statistically significant difference between groups (p>0.05). Uterine artery resistance index in the second gestational trimester (24 to 28 weeks) was also compared based on treatments. Patients treated with the H+ASA+omega association recorded the best resistance index, however, there was not statistically significant difference between groups (p>0.05). The group treated only with heparin recorded the lowest fetal weight, although there was not statistically significant difference between groups. Conclusion: Our results are preliminary, and a crude evaluation of the data shows a decrease in the pulsatility and resistance indices of the uterine art. With the increase of patients in the analysis, we hope that the statistical results can demonstrate this improvement of placental flow.