Publications by authors named "Njila Amaral"

8 Publications

  • Page 1 of 1

Maternal educational level and the risk of persistent post-partum glucose metabolism disorders in women with gestational diabetes mellitus.

Acta Diabetol 2018 Mar 29;55(3):243-251. Epub 2017 Dec 29.

Unit of Population Epidemiology, Department of Community Medicine, Primary Care, and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland.

Aims: Gestational diabetes mellitus (GDM) occurs in 5-15% of pregnancies, and lower maternal educational attainment has been associated with higher risk of GDM. We aimed to determine if maternal education level is associated with persistent post-partum glucose metabolism disorders in women with GDM.

Methods: Retrospective cohort study of women with GDM followed in 25 Portuguese health institutions between 2008 and 2012. Educational attainment was categorised into four levels. Prevalence of post-partum glucose metabolism disorders (type 2 diabetes mellitus, increased fasting plasma glucose or impaired glucose tolerance) was compared and adjusted odds ratios calculated controlling for confounders using logistic regression.

Results: We included 4490 women diagnosed with GDM. Educational level ranged as follows: 6.8% (n = 307) were at level 1 (≤ 6th grade), 34.6% (n = 1554) at level 2 (6-9th grade), 30.4% (n = 1364) at level 3 (10-12th grade) and 28.2% (n = 1265) at level 4 (≥ university degree). At 6 weeks post-partum re-evaluation, 10.9% (n = 491) had persistent glucose metabolism disorders. Educational levels 1 and 2 had a higher probability of persistent post-partum glucose metabolism disorders when compared to level 4 (OR = 2.37 [1.69;3.32], p < 0.001 and OR = 1.39 [1.09;1.76], p = 0.008, for level 1 and 2, respectively), an association that persisted in multivariable logistic regression adjusting for confounders (level 1 OR = 2.25 [1.53;3.33], p < 0.001; level 2 OR = 1.43 [1.09;1.89], p = 0.01).

Conclusions: Persistent post-partum glucose metabolism disorders are frequent in women with GDM and associated with lower maternal educational level. Interventions aimed at this risk group may contribute towards a decrease in prevalence of post-partum glucose metabolism disorders.
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March 2018

Impact of gestational weight gain on obstetric and neonatal outcomes in obese diabetic women.

BMC Pregnancy Childbirth 2015 Oct 8;15:249. Epub 2015 Oct 8.

Department of Obstetrics, Maternidade Bissaya Barreto - Centro Hospitalar e Universitário de Coimbra, Rua Augusta, 3000-061, Coimbra, Portugal.

Background: Both obesity and gestational diabetes mellitus are increasing in prevalence, being a major health problem in pregnancy with independent and additive impact on obstetrics outcomes. It is recognized that inadequate gestational weight gain is an independent risk factor for pregnancy-related morbidity. The aim of this study was to evaluate the effect of gestational weight gain on obstetric and neonatal outcomes in obese women with gestational diabetes.

Methods: Retrospective multicenter study of obese women with gestational diabetes. The assessed group was divided into three categories: women who gained below (<5 kg), within (5-9 kg) and above (>9 kg) the 2009 Institute of Medicine recommendations. Maternal and neonatal outcomes were compared and adjusted odds ratios calculated controlling for confounders.

Results: Only 35,1 % of obese women with gestational diabetes (n = 634) achieved the recommended gestational weight gain; 27,8 % (n = 502) gained below and 37,1 % (n = 670) above the recommendations. There was a positive correlation between gestational weight gain and neonatal birthweight (r = 0,225; p < 0,001). Gestational weight gain below recommendations was associated with lower odds for cesarean section, even adjusting for birthweight [aOR = 0,67 (0,54-0,85); p < 0,001]; lower odds for large for gestational age neonates [aOR = 0,39 (0,28-0,57); p < 0,001] and macrosomia [aOR = 0,34 (0,21-0,55); p < 0,001]. Excessive weight gain, even adjusting for birthweight, was associated with higher odds for cesarean section [aOR = 1,31 (1,07-1,61); p = 0,009], low Apgar score [aOR = 4,79 (1,19-19,21); p = 0,027], large for gestational age neonates [aOR = 2,32 (1,76-3,04); p < 0,001] and macrosomia [aOR = 2,39 (1,68-3,38); p < 0,001].

Conclusions: In obese women with gestational diabetes, a reduced gestational weight gain (<5 kg) is associated with better obstetric and neonatal outcomes than an excessive or even an adequate weight gain. Therefore, specific recommendations should be created since gestational weight gain could be a modifiable risk factor for adverse obstetric outcomes.
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October 2015

Interstitial pregnancy rupture at 15 weeks of pregnancy.

BMJ Case Rep 2014 Aug 25;2014. Epub 2014 Aug 25.

Medical Doctor of Obstetrics and Gynecology, Emergency Department of Beatriz Ângelo Hospital, Loures, Portugal.

Ectopic pregnancy occurs when the developing blastocyst becomes implanted outside the uterine cavity. Interstitial pregnancy is a rare type, representing 2-3%, of all ectopic pregnancies. It is located outside the uterine cavity in the segment of the fallopian tube that penetrates the muscular layer of the uterus. Therefore, it is a difficult and challenging diagnosis. We report a case of a 19-year-old girl who was admitted to our emergency department because of a ruptured interstitial pregnancy at 15 weeks of gestation.
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August 2014

Late stillbirth: a ten year cohort study.

Acta Med Port 2013 Jan-Feb;26(1):39-42. Epub 2013 Apr 24.

Department of Obstetrics and Gynecology, Alfredo da Costa Maternity, Lisbon, Portugal.

Introduction: Late fetal death is a desolating event that inspite the effort to implement new surveillance protocols in perinatal continues to defy our clinical pratice.

Objective: To examine etiological factors contributing to main causes and conditions associated with fetal death in late pregnancies over a 10-year period.

Methods: Retrospective cohort analysis of 208 late singleton stillbirth delived in a tertiary-perinatal referral maternity over a 10-year period. Clinical charts, laboratory data and feto-placental pathology findings were systematically reviewed.

Results: The incidence of late fetal demise was 3.5 per 1000 pregnancies. No significant trend in the incidence of stillbirth was demonstrated during the study period. Stillbirth was intrapartum in 12 (5.8%) cases and 72 (35%) were term pregnancies. Fourteen percent of cases were undersurveilled pregnancies. Mean gestacional age at diagnosis was 34 weeks. The primary cause of death was fetal, it was present in 59 cases, 25% were considered small for gestational age. Stillbirths were unexplained in 24.5% of cases. Maternal medical disorders were identified in 21%. Hypertensive disorders were frequent and associated with early gestacional age (p = 0.028).

Conclusion: There was no change in the incidence of late stillbirth during the 10 years under evaluation. The incidence was 3.5 ‰ which was identical to that described in developed countries. About one quarter of the stillbirths was unexplained. The most frequent maternal pathology was chronic hypertension.
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April 2014

[Pregnancy outcomes in women with pre-existing diabetes].

Rev Bras Ginecol Obstet 2012 Nov;34(11):494-8

Setor de Gestação de Alto Risco do Centro de Atenção à Mulher, Instituto de Medicina Integral Prof Fernando Figueira – IMIP – Recife, PE, Brasil.

Purpose: To describe trends in prevalence, indicators of care and pregnancy outcomes for women with pre-existing type I or type II diabetes.

Methods: Cohort study of all consecutive singleton pregnancies complicated by pre-existing type I or type II diabetes followed from 2004 to 2011 at a tertiary perinatal care centre (n=194). We collected data from the medical records and described trends in demographics, clinical history, indicators of care before or during pregnancy and glycaemic control. We also studied perinatal outcomes, including gestational age at delivery, mode of delivery, and birthweight.

Results: The overall incidence of pregestational diabetes was 4.4 per 1000, with no significant changes throughout the study period. The number of type 2 diabetes cases also remained constant. In 67% of cases delivery occurred after 37 weeks (maximum 80% in 2010 - 11). During this period there was a significant reduction in rates of elective caesarean section (p=0.03) and in the incidence of large infants for gestational age (p=0.04). Indicators of glycaemic control were favorable throughout pregnancy, with no significant trends detected during the study period. However, preconceptional care indicators were substandard, with no significant improvement.

Conclusions: A multidisciplinary approach to diabetic management and obstetric practice contributed to adequate glycaemic control throughout pregnancy and to improved pregnancy outcomes. Preconceptional care remains a key challenge.
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November 2012

[Diabetes in pregnancy - postpartum screening].

Acta Med Port 2012 May-Jun;25(3):165-8. Epub 2012 Jul 23.

Serviço de Obstetrícia, Maternidade Dr. Alfredo da Costa, Lisboa, Portugal.

Introduction: One third of women with gestational diabetes mellitus (GDM) will have diabetes or impaired glucose metabolism at postpartum screening.

Objective: Evaluate the percentage of women submitted postpartum screening and associate the result with maternal history.

Methods: Retrospective investigation of 1013 pregnancies with GDM (2005-2009). We divided the population into two groups according to the result: normal (group 1) and with diabetes or impaired glucose metabolism (group 2). For both groups we evaluated maternal age, body mass index, weight gain during pregnancy, need for insulin therapy, risk factors for GDM, and newborn weight.

Results: Postpartum screening was achieved in 76.8% of women (n=778). The test was considered normal (group 1) in 628 women (80.7%) and modified (group 2) in 150 women (19.3%). Group 2 had older women (median age 34 vs. 33 years; p-value 0.013), higher body mass index (28.5 vs. 25.8kg/cm2; p-value 0.000), more women with diabetes mellitus family history in first degree (50.3% vs. 39.9%; p-value 0.026) and prior personal history of macrosomia (12.1% vs 5.4%; p-value 0.003). Earlier diagnosis of GDM was also made in this group (27 vs. 31 weeks; p-value 0.000) and a higher percentage had made insulin therapy (41% vs. 15%; p-value 0.000), having started earlier (28 vs 30 weeks; p-value 0.010). There was a higher percentage of multiparous pregnant in group 2 (64% vs 49.4%; p-value 0.001) and a larger number of cases of newborns large for gestational age (17.1% vs 8.3%; p-value 0.001). Personal history of GDM and weight gain during pregnancy was similar in both groups.

Conclusions: Women who test abnormal in postpartum screening are usually older, heavier, multiparous, with a family related to DM patients and prior personal history of macrosomia. GDM diagnosis is made earlier in pregnancy, more often they need insulin therapy started ealier and there was a higher number of newborns large for gestational age.
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December 2013

[Genital tuberculosis: a rare cause of postmenopausal bleeding].

Acta Med Port 2010 Jul-Aug;23(4):723-6. Epub 2010 Jul 30.

Serviço de Ginecologia, Maternidade Dr. Alfredo da Costa, Lisboa.

Background: Tuberculosis remains a global health problem, being the genitourinary tract the second most common site for tuberculosis infection after the lungs. Genital tuberculosis is now undergoing a worrying recrudescence.

Case Report: We report two cases of postmenopausal women who presented with vaginal bleeding. General physical and gynecological examination detected no abnormality. Transvaginal pelvic ultrasound showed fluid in the endometrial cavity in both cases. The office hysteroscopy was suggestive of focal endometrial thickness and an endometrial biopsy was performed. The histopathologic examination of biopsies found epithelioid cell granulomas without malignant cells. Culture of the endometrium was positive for Mycobacterium tuberculosis. Involvement of other systems was not detected. The patients started receiving antituberculosis treatment.

Conclusion: Genital tuberculosis is rare in postmenopausal women and responsible for only approximately 1% of postmenopausal bleeding. However it is a curable disease and an early diagnosis is important and may prevent unnecessary invasive procedures for the patient.
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November 2010

Prospective risk of intrauterine death of monochorionic-diamniotic twins.

Am J Obstet Gynecol 2006 Jul 27;195(1):134-9. Epub 2006 Apr 27.

Department of Maternal-Fetal Medicine Maternity Dr Alfredo da Costa, Lisbon, Portugal.

Objective: The purpose of this study was to calculate the prospective risk of fetal death in monochorionic-diamniotic twins.

Study Design: We evaluated 193 monochorionic diamniotic twin pregnancies that were followed and delivered after 24 weeks. Surveillance included cardiotocography and sonography performed at least once weekly. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period.

Results: The fetal death rate was 5 of 193 pregnancies (2.6%; 95% CI, 1.1, 5.9); the prospective risk of stillbirth per pregnancy after 32 weeks of gestation was 1.2% (95% CI, 0.3% - 4.2%).

Conclusion: Under intensive surveillance, the prospective risk of fetal death in monochorionic-diamniotic pregnancies after 32 weeks of gestation is much lower than reported and does not support a policy of elective preterm delivery.
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July 2006