FOR THE BRAZILIAN GESTATIONAL DIABETES STUDY GROUPOBJECTIVE -To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS -This cohort study consecutively enrolledBrazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values Ն5.3 mmol/l (fasting), Ն10 mmol/l (1 h), and Ն8.6 mmol/l (2 h). WHO criteria require a plasma glucose Ն7.0 mmol/l (fasting) or Ն7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded.RESULTS -Among the 4,977 women studied, 2.4% (95% CI 2.0 -2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06 -1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86 -2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria.CONCLUSIONS -GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

OBJECTIVE:To assess the association between pre-gestational obesity and weight gain with cesarean delivery and labor complications. METHODS:A total of 4,486 women 20-28 weeks pregnant attending general prenatal care clinics of the national health system in Brazil from 1991 to 1995 were enrolled and followed up through birth. Body mass index categories based on prepregnancy weight and total weight gain were calculated. Associations between body mass index categories and labor complications were adjusted through logistic regression analysis. RESULTS:Obesity was present in 308 (6.9%) patients. Cesarean delivery was performed in 164 (53.2%) obese, 407 (43.1%) pre-obese, 1,045 (35.1%) normal weight and 64 (24.5%) underweight women. The relative risk for cesarean delivery in obese women was 1.8 (95% CI: 1.5-2.0) compared to normal weight women. Greater weight gain was particularly associated with cesarean among the obese (RR 4 th vs 2 nd weight gain quartile 2.2; 95% CI: 1.4-3.2). Increased weight at the beginning of pregnancy was associated with a significantly higher adjusted risk of meconium with vaginal delivery and perinatal death and infection in women submitted to cesarean section. Similarly, greater weight gain during pregnancy increased the risk for meconium and hemorrhage in women submitted to vaginal delivery and for prematurity with cesarean. CONCLUSIONS:Pre-gestational obesity and greater weight gain independently increase the risk of cesarean delivery, as well as of several adverse outcomes with vaginal delivery. These findings provide further evidence of the negative effects of prepregnancy obesity and greater gestational weight gain on pregnancy outcomes. INTRODUCTIONThe prevalence of overweight and obesity have substantially increased in the last decades, especially in women. Data from 1989 reported that 13.3% of Brazilian women were obese and a national survey conducted in 1996 showed that 10.2% of Brazilian women of reproductive age (20 to 49 years) were obese. Additionally the prevalence of overweight among Brazilian women in this age group was 36.8% in 1996. 13Medical complications such as diabetes and hypertension are significantly increased during pregnancy in obese patients. Fetal distress, meconium staining, arrest disorders, hemorrhage, difficult peridural access and operatory time are also increased in obese women. Furthermore, evidence of increased risk for cesarean section, endometritis, prolonged hospital stay, thromboembolic phenomena, anemia, urinary tract infection, prematurity and fetal demise have been described. 23Cesarean sections (C-sections) have become more frequent since 1970-80 around the world. Between 1965 and 1986, the rate of cesarean delivery in the United States increased from 4.5 to 24.1%. 21 From 1984 to1993, cesarean delivery was the most frequent major surgical procedure in the United States. Rates then declined slightly to 20.7% in 1996 and, more recently increased again in 2002 reaching 26.1%, the highest rate ever recorded.12 In a city of southern Brazi...

Hypertensive disorders commonly complicate pregnancy in Brazilian women. Risk factors for these disorders appear similar to those reported in other countries. Use of an inappropriately sized cuff to measure blood pressure may result in many false-positive diagnoses in more obese women. The considerably lower frequency of hypertensive disorders found in Manaus, in the Amazon region, warrants further study.

Fasting plasma glucose is a useful test for the screening of both subcategories of gestational diabetes, a threshold of 85 mg/dl being an acceptable option. Effective screening for the subcategory diabetes can be achieved using a cut point of 89 mg/dl. If greater emphasis is placed on the detection of impaired glucose tolerance, a lower value, 81 mg/dl, may be needed.

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