Cuban participation in and contributions to education, medical care and research on diabetes and pregnancy in Latin America dates back to the 1970s when the Latin American Diabetes Association was founded. The Cuban health system and its professionals recognized early the problems presented by diabetes during pregnancy for the health of an expectant mother and her children and assimilated and disseminated important lessons that became influential in the region. These included: importance of adopting a program within primary health care that offers national coverage for diabetic pregnant women, with a special focus on pre-conception monitoring of diabetic women; benefits of defining a specific range for application of a fasting glucose test to identify risk of gestational diabetes through selective screening for the disease; using insulin to treat gestational diabetes; controlling excessive weight at the beginning and during pregnancy; and underscoring the importance of interdisciplinary treatment of diabetes in pregnancy. The goal was to improve care and research in reproductive health for diabetic pregnant women and their children in Cuba.
KEYWORDS: Gestational diabetes, pregnancy, Latin America, Cuba
La diabetes gestacional es el trastorno endocrino que afecta más frecuentemente a las mujeres embarazadas y su prevalencia va en aumento. La prevalencia en Cuba es de aproximadamente 5.8%, y la prevalencia mundial oscila entre el 2% y el 18% en dependencia de los criterios que se apliquen. La diabetes gestacional puede conducir a resultados gestacionales adversos, tales como muerte fetal, parto prematuro, distocia, asfixia perinatal y complicaciones neonatales. Un diagnóstico rápido y preciso que permita el tratamiento temprano puede beneficiar tanto a la madre como al niño. La enfermedad es asintomática, por lo que las pruebas de laboratorio clínico desempeñan un papel clave en su pesquisa y diagnóstico. El enfoque de Cuba en la pesquisa y el diagnóstico de la diabetes se diferencia de algunas prácticas internacionales. A todas las mujeres embarazadas en Cuba se les realiza una prueba en ayunas de glucosa en plasma y se diagnostican mediante los criterios modificados de la OMS. Algunas recomendaciones internacionales incluyen omitir la etapa de pesquisa y en su lugar, seguir los criterios de diagnóstico del estudio Hiperglucemia y Resultados Adversos del Embarazo. En Cuba, los resultados de la gestación en las mujeres con diabetes (incluyendo la diabetes gestacional) son satisfactorios (preeclampsia 5%; parto prematuro 12%; macrosomía neonatal 7.5%; anormalidades congénitas 4.3% y muerte perinatal 4.8%). Estos datos no indican una necesidad de cambiar los criterios establecidos de pesquisa y diagnóstico.
PALABRAS CLAVE diabetes gestacional, pesquisa, diagnóstico, detección precoz, diagnóstico temprano, Cuba
Gestational diabetes is the most common endocrine disorder affecting pregnant women and its prevalence is on the rise. Prevalence in Cuba is about 5.8%, and global prevalence ranges from 2% to 18% depending on the criteria applied. Gestational diabetes can lead to adverse gestational outcomes, such as fetal death, preterm delivery, dystocia, perinatal asphyxia and neonatal complications. Prompt, accurate diagnosis allowing early treatment can benefit both mother and child. The disease is asymptomatic, so clinical laboratory testing plays a key role in its screening and diagnosis. Cuba’s approach to diabetes screening and diagnosis differs from some international practices. All pregnant women in Cuba are screened with a fasting plasma glucose test and diagnosed using modified WHO criteria. Some international recommendations are to skip the screening step and instead follow the diagnostic criteria of the Hyperglycemia and Adverse Pregnancy Outcomes study. In Cuba, gestational outcomes for women with diabetes (including gestational diabetes) are satisfactory (preeclampsia 5%; preterm delivery 12%; neonatal macrosomia 7.5%; congenital abnormalities 4.3% and perinatal deaths 4.8%). These data do not indicate a need to change established screening and diagnostic criteria.
KEYWORDS Gestational diabetes, screening, diagnosis, early detection, early diagnosis, Cuba
INTRODUCTION Fetal macrosomia is the most important complication in infants of women with diabetes, whether preconceptional or gestational. Its occurrence is related to certain maternal and fetal conditions and negatively affects maternal and perinatal outcomes. The definitive diagnosis is made at birth if a newborn weighs >4000 g.
OBJECTIVE Identify which maternal and fetal conditions could be macrosomia predictors in infants born to Cuban mothers with gestational diabetes.
METHODS A case-control study comprising 236 women with gestational diabetes who bore live infants (118 with macrosomia and 118 without) was conducted in the América Arias University Maternity Hospital, Havana, Cuba, during 2002–2012. The dependent variable was macrosomia (birth weight >4000 g). Independent maternal variables included body mass index at pregnancy onset, overweight or obesity at pregnancy onset, gestational age at diabetes diagnosis, pregnancy weight gain, glycemic control, triglycerides and cholesterol. Fetal variables examined included third-semester fetal abdominal circumference, estimated fetal weight at ≥28 weeks (absolute and percentilized by Campbell and Wilkin, and Usher and McLean curves). Chi square was used to compare continuous variables (proportions) and the student t test (X ± SD) for categorical variables, with significance threshold set at p <0.05. ORs and their 95% CIs were calculated.
RESULTS Significant differences between cases and controls were found in most variables studied, with the exception of late gestational diabetes diagnosis, total fasting cholesterol and hypercholesterolemia. The highest OR for macrosomia were for maternal hypertriglyceridemia (OR 4.80, CI 2.34–9.84), third-trimester fetal abdominal circumference >75th percentile (OR 7.54, CI 4.04–14.06), and estimated fetal weight >90th percentile by Campbell and Wilkin curves (OR 4.75, CI 1.42–15.84) and by Usher and McLean curves (OR 8.81, CI 4.25–18.26).
CONCLUSIONS Most variables assessed were predictors of macrosomia in infants of mothers with gestational diabetes. They should therefore be taken into account for future studies and for patient management. Wide confidence intervals indicate uncertainty about the magnitude of predictive power.
KEYWORDS Fetal macrosomia, fetal diseases, gestational diabetes, risk factors, risk prediction, Cuba
Se describe la creación, el desarrollo, la ampliación y la organización del Programa Nacional de Atención Integral a la Gestante con Diabetes, así como los cambios ocurridos en los servicios de salud desde 1959. Actualmente, el Programa se encuentra implementado en todo el país y es supervisado por un grupo de trabajo que aborda la salud reproductiva de la mujer con diabetes y su atención durante la gestación. Se destaca la importancia de la atención preconcepcional a la mujer con diabetes, la necesidad de generalizar el Programa a nivel nacional y de pesquisar la diabetes gestacional en la atención primaria de salud.
PALABRAS CLAVE: Diabetes mellitus, diabetes en el embarazo, gestación en la mujer diabética, diabetes gestacional, atención preconcepcional, resultados de la gestación, complicaciones de la gestación, gestación de alto riesgo, atención prenatal, pesquisa, Cuba
Establishment, progressive development, expansion and organization of Cuba’s National Comprehensive Diabetes and Pregnancy Program is described, including changes in related health services since 1959. Currently implemented throughout the country, the Program is supervised by a working group and addresses diabetic women’s reproductive health and care during pregnancy. The importance of preconception care for diabetic women is emphasized, as well as the need to increase Program uptake nationally, including screening for gestational diabetes in primary care.
KEYWORDS Diabetes mellitus, pregnancy in diabetes; pregnancy in diabetics; gestational diabetes; diabetes, pregnancy-induced; preconception care; pregnancy outcomes; pregnancy complications; high-risk pregnancy; antenatal care; screening; Cuba
