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O diabetes mellitus gestacional (DMG) é definido, pela Organização Mundial da Saúde (OMS), como uma intolerância aos carboidratos de gravidade variável, que se inicia durante a gestação atual e não preenche os critérios diagnósticos de diabetes mellitus franco.
É o problema metabólico mais comum na gestação com taxas de aproximadamente 17% com os métodos diagnósticos atuais, porém sua incidência vem aumentando em paralelo a obesidade na população.
Existem alguns fatores de risco que estão associados a maior frequência de diabetes gestacional, mas independente deles todas as gestantes devem realizar a investigação de DMG.
Os principais fatores de risco para DMG são:
- Idade materna avançada
- Sobrepeso, obesidade ou ganho excessivo de peso na gravidez atual
- História familiar de diabetes em parentes de primeiro grau
- Diabetes em gestação prévia
- Antecedente de óbito fetal
- Macrossomia fetal
- Hipertensão arterial
- Síndrome de ovários policísticos
- Uso de corticoides
Para o diagnóstico do diabetes gestacional deve-se solicitar na primeira consulta a glicemia de jejum.
Se o valor encontrado for ≥ 126 mg/dL, será feito o diagnóstico de diabetes mellitus prévio
(overt diabetes) diagnosticado na gestação.
Se a glicemia plasmática em jejum for ≥ 92 mg/dL e < 126 mg/dL, será feito o diagnóstico de DMG.
Em ambos os casos, deve-se confirmar o resultado com uma segunda dosagem da glicemia de jejum.
Caso a glicemia antes da 20ª semana seja < 92 mg/dL, todas as gestantes deverão realizar um a curva glicêmica ou TOTG ( teste oral de tolerância a glicose ) realizado no segundo trimestre, entre a 24a e 28a semanas de gestação. A gestante comparece ao laboratório em jejum , realiza a primeira coleta de sangue, após ingere 75 gramas de glicose oral, permanece no laboratório em repouso para as próximas coletas que serão realizadas em 1 hora e 2 horas após a ingesta da glicose.
Os valores considerados normais para o TOTG são:
- Jejum até 92
- Após 1 hora – 180
- Após 2 horas –153
O diagnóstico é confirmado quando pelo menos um dos valores encontra-se fora da meta.
O tratamento inicial do DMG consiste em orientação alimentar que permita o ganho de peso adequado e um bom controle metabólico.
A prática de atividade física também deve fazer parte do tratamento do DMG, respeitando-se as contraindicações obstétricas.
O acompanhamento nutricional é fundamental para ajuste de dieta através da escolha dos alimentos e combinações que favoreçam o bom controle das glicemias.
Deve-se dar preferência ao consumo de alimentos que contenham carboidratos com baixo índice glicêmico. A dieta com baixo índice glicêmico no DMG se associou à diminuição da necessidade de indicar o uso de insulina e menor ganho de peso ao nascer.
Após o ajuste da dieta com a nutricionista recomenda-se monitorar as glicemias capilares. Essa medida é feita colocando-se uma gota de sangue da ponta do dedo em uma fita reagente inserida em um aparelho chamado glicosimetro. Esse aparelho fará a leitura, mostrando no visor o valor da glicemia capilar, conforme ilustrado na figura 2.
Recomenda-se o monitoramento das glicemias capilares quatro vezes ao dia (jejum, pós café, pós almoço e pós jantar) nas gestantes com controle de dieta e naquelas em uso de insulina incluem-se as medidas pré-refeições, totalizando até 7 medidas ao dia.
O tratamento do DMG tem por objetivo minimizar ou até mesmo evitar as complicações decorrentes do mau controle glicêmico, entre elas:
- Feto grande para a idade gestacional ou macrossomia fetal;
- Polidrâmnio;
- Trabalho de parto prematuro;
- Ruptura prematura de membranas;
- Óbito fetal;
- Desconforto respiratório do recém-nascido;
- Na vida adulta síndrome metabólica, hipertensão e diabetes.
Após 2 semanas de dieta, se os níveis glicêmicos permanecerem elevados (jejum ≥90-95 mg/dL e 1 hora pós-prandial ≥ 140 mg/dL ou 2 horas pós-prandiais ≥ 120 mg/dL), deve-se iniciar tratamento farmacológico. Também pode-se utilizar o critério de crescimento fetal para início da insulinoterapia quando a medida da circunferência abdominal fetal for igual ou superior ao percentil 75 em uma ecografia realizada entre a 29a e a 33a semanas de gestação.
No caso de indicação/necessidade de iniciar tratamento farmacológico será importante mais uma vez o trabalho em equipe pois neste caso o endocrinologista será indispensável na equipe de cuidados com a gestante/bebê.
A insulina é a primeira escolha na terapêutica medicamentosa para controle glicêmico no período gestacional, devido à sua eficácia comprovada e à pequena passagem placentária, porém em algumas situações específicas o endocrinologista poderá considerar o uso da metformina.
Não se indica cesariana em razão do DMG, sendo a via de parto uma decisão obstétrica.
As gestantes com ótimo controle metabólico e que não apresentam antecedentes obstétricos de morte perinatal, macrossomia ou complicações associadas, como hipertensão, podem aguardar a evolução espontânea para o parto até o termo.
Quando apesar de dieta adequada e insulinoterapia não houver controle metabólico adequado o parto poderá estar indicado a partir de 37 semanas.
No caso de macrossomia (feto acima de 4000 gramas) está indicado o parto independentemente da idade gestacional devido ao risco aumentado de óbito fetal.
No pós-parto, os níveis de glicemia devem ser observados, suspendendo-se a insulina basal. Orienta-se também a manutenção de uma dieta saudável. A maioria das mulheres apresenta normalização das glicemias nos primeiros dias após o parto. Todas as gestantes com DMG deverão realizar novo TOTG após 6 semanas pós-parto pois o mesmo é considerado padrão-ouro para o diagnóstico de diabetes após a gestação
O aleitamento materno deve ser estimulado pois além dos benefícios ao bebê, está associado à prevenção do diabetes tipo 2 em mulheres com histórico de DMG.
A gestante com diagnóstico de DMG precisa de um bom acompanhamento pré-natal com equipe composta por obstetra, endocrinologista, nutricionista, educador físico e pediatra, profissionais que estarão orientando, informando e utilizando todos os conhecimentos disponíveis para um bom desfecho materno fetal.
Porém é preciso sentir-se acolhida e amparada pela família, evitando julgamentos e favorecendo um ambiente propício para melhora dos hábitos alimentares e prática de atividade física, que certamente contribuirá para o bem-estar e qualidade de vida de todos.
Fonte:
Protocolos assistenciais – Marcelo Zugaib – 5ª edição
Consenso SBD 2019-2020
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Fernanda Torino[/fusion_title][fusion_title title_type=”text” rotation_effect=”bounceIn” display_time=”1200″ highlight_effect=”circle” loop_animation=”off” highlight_width=”9″ highlight_top_margin=”0″ before_text=”” rotation_text=”” highlight_text=”” after_text=”” title_link=”off” link_url=”” link_target=”_self” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” content_align_medium=”” content_align_small=”” content_align=”left” size=”6″ font_size=”” animated_font_size=”” fusion_font_family_title_font=”Poppins” fusion_font_variant_title_font=”700″ line_height=”” letter_spacing=”” text_shadow=”no” text_shadow_vertical=”” text_shadow_horizontal=”” text_shadow_blur=”0″ text_shadow_color=”” margin_top_medium=”” margin_right_medium=”” margin_bottom_medium=”” margin_left_medium=”” margin_top_small=”” margin_right_small=”” margin_bottom_small=”” margin_left_small=”” margin_top=”” margin_right=”” margin_bottom=”” margin_left=”” margin_top_mobile=”” margin_bottom_mobile=”” text_color=”#202020″ animated_text_color=”” highlight_color=”” style_type=”default” sep_color=”” link_color=”” link_hover_color=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]Ginecologista e Obstetra, CRM: 19772, RQE: 11733[/fusion_title][fusion_text columns=”” column_min_width=”” column_spacing=”” rule_style=”default” rule_size=”” rule_color=”” content_alignment_medium=”” content_alignment_small=”” content_alignment=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” margin_top=”” margin_right=”” margin_bottom=”10px” margin_left=”” font_size=”” fusion_font_family_text_font=”” fusion_font_variant_text_font=”” line_height=”” letter_spacing=”” text_color=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]Ginecologia e Obstetrícia | Pré-Natal de Alto Risco | Gestação de Alto Risco[/fusion_text][fusion_text columns=”” column_min_width=”” column_spacing=”” rule_style=”default” rule_size=”” rule_color=”” content_alignment_medium=”” content_alignment_small=”” content_alignment=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” margin_top=”0px” margin_right=”” margin_bottom=”10px” margin_left=”” font_size=”15px” fusion_font_family_text_font=”Poppins” fusion_font_variant_text_font=”400italic” line_height=”” letter_spacing=”” text_color=”#7e858e” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]“Conhecemos as várias funções exercidas pelas mulheres, por isso é necessário que o cuidado englobe todos os aspectos da vida . Sendo múltipla não pode ser tratada como parte.”[/fusion_text][fusion_button link=”https://grupoelasbrasilia.com.br/fernandatorino/” text_transform=”” title=”” target=”_self” link_attributes=”” alignment_medium=”” alignment_small=”” alignment=”” modal=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” color=”default” button_gradient_top_color=”” button_gradient_bottom_color=”” button_gradient_top_color_hover=”” button_gradient_bottom_color_hover=”” accent_color=”” accent_hover_color=”” type=”” bevel_color=”” border_width=”” border_radius=”” border_color=”” border_hover_color=”” size=”small” stretch=”default” margin_top=”” margin_right=”” margin_bottom=”” margin_left=”” icon=”fusion-prefix-fa-message-medical” icon_position=”left” icon_divider=”no” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]CONHEÇA A MÉDICA[/fusion_button][/fusion_builder_column_inner][/fusion_builder_row_inner][/fusion_builder_column][fusion_builder_column type=”1_6″ layout=”1_6″ align_self=”auto” content_layout=”column” align_content=”flex-start” valign_content=”flex-start” content_wrap=”wrap” spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” order_medium=”0″ order_small=”0″ hover_type=”none” border_color=”” border_style=”solid” box_shadow=”no” box_shadow_blur=”0″ box_shadow_spread=”0″ box_shadow_color=”” box_shadow_style=”” background_type=”single” gradient_start_position=”0″ gradient_end_position=”100″ gradient_type=”linear” radial_direction=”center center” linear_angle=”180″ background_color=”” background_image=”” background_image_id=”” background_position=”left top” background_repeat=”no-repeat” background_blend_mode=”none” filter_type=”regular” filter_hue=”0″ 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padding_top=”6%” admin_label=”Call to Action Agendamento” admin_toggled=”yes” background_image=”https://ml1ca8kph5lh.i.optimole.com/f8pwKbQ-zroGwOxF/w:auto/h:auto/q:auto/https://grupoelasbrasilia.com.br/wp-content/uploads/2021/05/cta-agende-sua-consulta.jpg” padding_bottom=”5%” padding_left=”0px” padding_right=”0px” background_color=”rgba(0,0,0,0.6)”][fusion_builder_row][fusion_builder_column type=”1_1″ layout=”1_2″ align_self=”center” content_layout=”column” align_content=”flex-start” content_wrap=”wrap” spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” order_medium=”0″ order_small=”0″ hover_type=”none” border_color=”” border_style=”solid” box_shadow=”no” box_shadow_blur=”0″ box_shadow_spread=”0″ box_shadow_color=”” box_shadow_style=”” background_type=”single” gradient_start_position=”0″ gradient_end_position=”100″ gradient_type=”linear” radial_direction=”center center” linear_angle=”180″ background_color=”” background_image=”” background_image_id=”” background_position=”left top” background_repeat=”no-repeat” background_blend_mode=”none” animation_type=”fade” animation_direction=”right” animation_speed=”1.0″ animation_offset=”” filter_type=”regular” filter_hue=”0″ filter_saturation=”100″ filter_brightness=”100″ filter_contrast=”100″ filter_invert=”0″ filter_sepia=”0″ filter_opacity=”100″ filter_blur=”0″ filter_hue_hover=”0″ filter_saturation_hover=”100″ filter_brightness_hover=”100″ filter_contrast_hover=”100″ filter_invert_hover=”0″ filter_sepia_hover=”0″ filter_opacity_hover=”100″ filter_blur_hover=”0″ padding_right=”” last=”true” border_position=”all” padding_right_small=”0px” first=”true”][fusion_title title_type=”text” rotation_effect=”bounceIn” display_time=”1200″ highlight_effect=”circle” loop_animation=”off” highlight_width=”9″ highlight_top_margin=”0″ before_text=”” rotation_text=”” highlight_text=”” after_text=”” content_align_medium=”” content_align_small=”center” content_align=”center” size=”2″ font_size=”” animated_font_size=”” line_height=”” letter_spacing=”” dimensions_medium=”” dimensions_small=”” text_color=”#dbc5a6″ animated_text_color=”” highlight_color=”” style_type=”default” sep_color=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” sticky_display=”normal,sticky” class=”” id=”” fusion_font_variant_title_font=”700″ fusion_font_family_title_font=”Open Sans” margin_bottom=”30px”]Agende sua consulta[/fusion_title][fusion_button link=”https://grupoelasbrasilia.com.br/contato/” text_transform=”” title=”” target=”_self” link_attributes=”” alignment_medium=”” alignment_small=”” alignment=”center” modal=”” color=”default” button_gradient_top_color=”” button_gradient_bottom_color=”” button_gradient_top_color_hover=”” button_gradient_bottom_color_hover=”” accent_color=”” 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