Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad
Digital
- Autores:
-
Arenas-Camacho, Laura Daniela
- Tipo de recurso:
- Fecha de publicación:
- 2025
- Institución:
- Universidad de Santander
- Repositorio:
- Repositorio Universidad de Santander
- Idioma:
- spa
- OAI Identifier:
- oai:repositorio.udes.edu.co:001/11895
- Palabra clave:
- Diabetes gestacional
Desenlaces
Complicaciones
Recién nacido
Cardiopatías
Gestational Diabetes
Outcomes
Complications
Newborn
Heart disease
- Rights
- openAccess
- License
- http://purl.org/coar/access_right/c_abf2
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Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| dc.title.translated.none.fl_str_mv |
Adverse neonatal outcomes in children born to mothers with gestational diabetes with concomitant overweight - obesity |
| title |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| spellingShingle |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad Diabetes gestacional Desenlaces Complicaciones Recién nacido Cardiopatías Gestational Diabetes Outcomes Complications Newborn Heart disease |
| title_short |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| title_full |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| title_fullStr |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| title_full_unstemmed |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| title_sort |
Desenlaces Adversos Neonatales en Hijos de Madres con Diabetes Gestacional Concomitante con Sobrepeso - Obesidad |
| dc.creator.fl_str_mv |
Arenas-Camacho, Laura Daniela |
| dc.contributor.advisor.none.fl_str_mv |
Africano-León, Martha Lucia Martínez-Vega, Ruth Aralí |
| dc.contributor.author.none.fl_str_mv |
Arenas-Camacho, Laura Daniela |
| dc.contributor.jury.none.fl_str_mv |
Chacón-Rey, Jorge Andres Hurtado-Sierra, Daniel Eduardo Giraldo-Castrillón, Yessica María |
| dc.subject.proposal.spa.fl_str_mv |
Diabetes gestacional Desenlaces Complicaciones Recién nacido Cardiopatías |
| topic |
Diabetes gestacional Desenlaces Complicaciones Recién nacido Cardiopatías Gestational Diabetes Outcomes Complications Newborn Heart disease |
| dc.subject.proposal.eng.fl_str_mv |
Gestational Diabetes Outcomes Complications Newborn Heart disease |
| description |
Digital |
| publishDate |
2025 |
| dc.date.accessioned.none.fl_str_mv |
2025-06-24T19:34:15Z |
| dc.date.available.none.fl_str_mv |
2025-06-24T19:34:15Z |
| dc.date.issued.none.fl_str_mv |
2025-02-17 |
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Trabajo de grado - Especialización |
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http://purl.org/coar/version/c_71e4c1898caa6e32 |
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Text |
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info:eu-repo/semantics/masterThesis |
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http://purl.org/redcol/resource_type/TM |
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info:eu-repo/semantics/submittedVersion |
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Universidad de Santander |
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T 103.25 A726d |
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Repositorio Digital Institucional Universidad de Santander |
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https://repositorio.udes.edu.co |
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https://repositorio.udes.edu.co/handle/001/11895 |
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Universidad de Santander T 103.25 A726d Repositorio Digital Institucional Universidad de Santander |
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https://repositorio.udes.edu.co https://repositorio.udes.edu.co/handle/001/11895 |
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spa |
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spa |
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España-Dorado S, González-Dagua Y, Riascos-Melo J, Ortiz-Martínez R, Chagüendo-García J. Prevalence of gestational diabetes and identification of associated factors and maternal-perinatal outcomes in Colombia, following the implementation of the new IADPSG criteria. Rev. Fac. Med. 2021;69(2):e80195. Rojas J. Prevalencia de obesidad y diabetes gestacional en madres gestantes de Floridablanca, Santander. Repositorio UNAB, 2015. Vargas-Sanabria A, Niño M, Acosta AL, Pérez L. Relación entre obesidad gestacional y desenlaces perinatales adversos: Estudio multicéntrico. Andes pediatr. 2021;92(4):548-555. American Diabetes Association. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019. Diabetes Care. 2018;42(1):S13-S28. Kouhkan A, Najafi L, Malek M, et al. Gestational diabetes mellitus: Major risk factors and pregnancy related outcomes: A cohort study. International Journal of Reproductive BioMedicine. 2021;19(9):827–836. Dagua YC, Riascos-Melo J, Ortiz-Martínez R, Cha-güendo-García J. Prevalence of gestational diabetes and identification of associated factors and maternal-perinatal outcomes in Colombia, following the implementation of the new IADPSG criteria. Rev. Fac. Med. 2021;69(2):e80195. Rincón DM, Villamizar KY. Incidencia de diabetes gestacional en Bucaramanga durante los años 2016 y 2017 [Tesis de grado Enfermería] Bucaramanga, Universidad de Santander; 2018. Guía de actualización en Diabetes. ¿Cúal es el tratamiento?. 2015 American Diabetes Association. Gestational Diabetes Mellitus. Diabetes Care. 2004;27(1):S88-90. Restrepo O. Diabetes y embarazo - Actualización. Revista Colombiana de Obstetricia y Ginecología. 2000;51(1). Basu M, Garg V. Maternal hyperglycemia and fetal cardiac development: Clinical impact and underlying mechanisms. Birth defects research. 2018;110(20):1504-1516. Van der Burg J, Sen S, Chomitz V, et al. The role of systemic inflammation linking maternal body mass index to neurodevelopment in children: Inflammation and neurodevelopment. Pediatr Res [Internet]. 2016;79(1-1):3-12. Cancello R. Obesity and Inflammation in Pregnancy. En: Ferrazzi E, Sears B,Biosci Rep. Metabolic Syndrome and Complications of Pregnancy. The Potential Preventive Role of Nutrition. Switzerland: Springer International Publishing. 2015;65-75. Wisse B. The Inflammatory Syndrome: The Role of Adipose Tissue Cytokines in Metabolic Disorders Linked to Obesity. J Am Soc Nephrol. 2004;15(11):2792-800. Catalano P, Shankar K. Obesity and Pregnancy: Mechanisms of Short Term and Long Term Adverse Consequences for Mother and Child. BMJ. 2017;356:1–16. MacInnis N, Woolcott C, McDonald S, Kuhle S. Population attributable risk fractions of maternal overweight and obesity for adverse perinatal outcomes. Scientific reports. 2016;6(1):22895. McIntyre H, Oats J, Kihara A, et al. Update on diagnosis of hyperglycemia in pregnancy and gestational diabetes mellitus from FIGO's Pregnancy & Non-Communicable Diseases Committee. Int J Gynaecol Obstet. 2021;154(2):189-194. Sweeting A, Wong J, Murphy H, Ross G. A Clinical Update on Gestational Diabetes Mellitus. Endocrine Reviews. 2022;43:763–793. Chen YT, Zhang T, Chen C, et al. Associations of early pregnancy BMI with adverse pregnancy outcomes and infant neurocognitive development. Scientific Reports. 2021;11(1). Ministerio de Salud y Protección Social. Análisis de situación en Salud (ASIS) Colombia, 2020. Dirección de Epidemiología y Demografía [internet] Bogotá; 2020. [Consultado 03 octubre 2022] Disponible en: www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/ED/PSP/asis-2020-colombia.pdf Ministerio de la Protección Social, Colciencias, Cendex. Encuesta Nacional de Salud 2007 [internet] Bogotá; 2009. [Consultado 01 octubre 2022] Disponible en: http://www.minsalud.gov.co/Documentos%20y%20Publicaciones/ENCUESTA%20 NACIONAL.pdf Moll U, Olsson H, Landin-Olsson M. Impact of Pregestational Weight and Weight Gain during Pregnancy on Long-Term Risk for Diseases. PLoS ONE. 2017;12(1):e0168543. Ijäs H, Koivunen S, Raudaskoski T, et al. Independent and concomitant associations of gestational diabetes and maternal obesity to perinatal outcome: A register-based study. PLoS ONE. 2019;14(8):e0221549. González-Plaza E, Bellart J, Martínez-Verdú M, et al. Pre-pregnancy overweight and obesity prevalence and relation to maternal and perinatal outcomes. Enfermeria Clinica. 2022;32:S23-S30. Fox HK, Callander EJ. Uso de los servicios de salud y costos del sistema de salud asociados con la diabetes durante el embarazo en Australia. Nutr Metab Cardiovasc Dis. 2021;31:1427-433. Speight J, Holmes-Truscott E, Hendrieckx C, Skovlund S, Cooke D. Evaluación del impacto de la diabetes en la calidad de vida: ¿qué nos han enseñado los últimos 25 años? Diabetes Med. 2020;37:483-492. Atlas de diabetes de la FID. Disponible en https://diabetesatlas.org/ Solis JM, Perichart O, Montoya A, et al. Gestational Weight Gain Influences the Adipokine-Oxidative Stress Association during Pregnancy. Obesity Facts. 2021;14(6):604-612. Uebel K, Pusch K, Gedrich K, et al. Effect of maternal obesity with and without gestational diabetes on offspring subcutaneous and preperitoneal adipose tissue development from birth up to year-1. BMC Pregnancy and Childbirth. 2014;14(1). Departamento de Estadística. Atención de trabajos de parto en el año 2021. Clínica San Luis, Bucaramanga. Consultado: 01 Octubre de 2022. Ministerio de la Protección Social – Colciencias. Guía de Práctica Clínica Para El Diagnóstico, Tratamiento y Seguimiento de La Diabetes Gestacional. 2016. Kwapong Y, Boakye E, Wang G, et al. Maternal Glycemic Spectrum and Adverse Pregnancy and Perinatal Outcomes in a Multiracial US Cohort. Journal of Cardiovascular Development and Disease. 2022;9(6). 10° Edición 2021. Atlas de diabetes de la FID. Disponible en: https://diabetesatlas.org/ López, G. Tratamiento de la diabetes en el embarazo: ¿algo nuevo?. Revista Médica Clínica Las Condes. 2016;27(2):257-265. World Health Organization. The World Health Organization [internet] Suiza. [Consultado 01 octubre 2022] Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/obesity-and-overweight Soares de Souza É, Saunders C, do Carmo C, et al. Gestational weight gain and adverse maternal and perinatal outcomes among women with gestational diabetes mellitus according to International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria: A cross sectional study. Clinical Nutrition ESPEN. 2022;50:207-211. Hernández R, Hernández V, Sánchez R. Control preconcepcional y diabetes gestacional. Revisión sistemática y estado del arte. Biociencias. 2020;15(1):41-50. Karasneh R, Migdady F, Alzoubi K, et al. Trends in maternal characteristics, and maternal and neonatal outcomes of women with gestational diabetes: A study from Jordan. Annals of Medicine and Surgery. 2021;67. Xie D, Yang W, Wang A, et al. Effects of pre-pregnancy body mass index on pregnancy and perinatal outcomes in women based on a retrospective cohort. Scientific Reports. 2021;11(1). Comas M, Moreno A, Burgaya N, et al. The influence of obesity and diet quality on fetal growth and perinatal outcome. Nutrición Hospitalaria. 2022. Corcillo A, Quansah D, Kosinski C, et al. Impact of Risk Factors on Short and Long-Term Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: A Prospective Longitudinal Cohort Study. Frontiers in Endocrinology. 2022;13. Chen Y, Zhang T, Chen C, et al. Associations of early pregnancy BMI with adverse pregnancy outcomes and infant neurocognitive development. Scientific Reports. 2021;11(1). Sun Y, Shen Z, Zhan Y, et al. Effects of pre-pregnancy body mass index and gestational weight gain on maternal and infant complications. BMC Pregnancy and Childbirth. 2020;20(1). Dornelles V, Hentschke M, Badalotti M, et al. Influence of overweight and obesity on perinatal outcomes in assisted reproduction: a retrospective cohort study. BMC Pregnancy and Childbirth. 2022;22(1). Shokry E, Marchioro L, Uhl O. et al. Transgenerational cycle of obesity and diabetes: investigating possible metabolic precursors in cord blood from the PREOBE study. Acta Diabetol. 2019;56:1073-1082. Lachica L, Gómez MC. ¿Cuál es el tratamiento más adecuado para las pacientes con diabetes mellitus gestacional?. 2015 López G. Tratamiento de la diabetes en el embarazo: ¿algo nuevo?. Revista Médica Clínica Las Condes. 2016;27(2): 257-265. Alwan N, Tuffnell DJ, West J. Treatments for gestational diabetes. Cochrane Database Syst Rev. 2009;(3):CD003395. Al-Biltagi M, El Razaky O, El Amrousy D. Cardiac changes in infants of diabetic mothers. World J Diabetes. 2021;12(8):1233-1247. Rogozińska E, Marlin N, Jackson L, Rayanagoudar G, et al. Effects of antenatal diet and physical activity on maternal and fetal outcomes: individual patient data meta-analysis and health economic evaluation. Health Technol Assess. 2017;21(41):1-158. Pagotto V, Posadas ML, Salzberg S, Pochettino PA. Diabetes mellitus gestacional en un hospital de la Ciudad de Buenos Aires, Argentina: incidencia, tratamiento, y frecuencia de tamizaje para reclasificación luego del parto. Rev Fac Cien Med Univ Nac Cordoba. 2022;79(3):248-53. Mocellin L, Gomes H, Sona L, Giacomini G, Pizzuti E, Nunes G, et al. Gestational diabetes mellitus prevalence in Brazil: a systematic review and meta-analysis. Cadernos de Saúde Pública. 2024;40:e00064919. Garmendia M, Mondschein S, Montiel B, Kusanovic JP. Trends and predictors of gestational diabetes mellitus in Chile. Int J Gynaecol Obstet. 2020;148(2):210-218. Ramírez-Torres MA. The importance of gestational diabetes beyond pregnancy. Nutr Rev. 2013;71(1):S37-41. Yen I, Lee C, Lin M, Fan K, Wei J, Chen K, et al. Overweight and obesity are associated with clustering of metabolic risk factors in early pregnancy and the risk of GDM. PLoS One. 2019;14(12):e0225978. Nagler L, Eißmann C, Wasenitz M, Bahlmann F, Al Naimi A. The association between maternal obesity and fetomaternal outcomes in twin pregnancies. Plos one. 2024;19(7):e0306877. Black M, Sacks D, Xiang A, Lawrence J. The relative contribution of prepregnancy overweight and obesity, gestational weight gain, and IADPSG-defined gestational diabetes mellitus to fetal overgrowth. Diabetes Care. 2013;36(1):56-62. Lin Y, Lin M, Pai L, Fang J, Mou C, Sung F, et al. Population-based study on birth outcomes among women with hypertensive disorders of pregnancy and gestational diabetes mellitus. Sci Rep. 2021;11(1):17391. McLean S, Boots C. Obesity and Miscarriage. Semin Reprod Med. 2023;41(3-04):80-86. Wang R, Deng Z, Chen G, Dai F, Xia L. Obesity and recurrent spontaneous abortion: the crucial role of weight management in pregnancy. Reprod Biol Endocrinol. 2025;23(1):10. Practice Committee of the American Society for Reproductive Medicine. Obesity and reproduction: a committee opinion. Fertil Steril. 2015;104(5):1116-26. American Diabetes Association Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2025. Diabetes Care. 2025;48(1):S306-S320. Owen M, Baker B, Scott E, Forbes K. Interaction between metformin, folate and vitamin B12 and the potential impact on fetal growth and long-term metabolic health in diabetic pregnancies. International journal of molecular sciences. 2021;22(11):5759. Kong L, Nilsson I, Gissler M, Lavebratt C. Associations of Maternal Diabetes and Body Mass Index With Offspring Birth Weight and Prematurity. JAMA Pediatr. 2019;173(4):371-378. Benhalima K, Robyns K, Van Crombrugge P, Deprez N, Seynhave B, Devlieger R, Verhaeghe J, Mathieu C, Nobels F. Differences in pregnancy outcomes and characteristics between insulin- and diet-treated women with gestational diabetes. BMC Pregnancy Childbirth. 2015;15:271. Barbry F, Lemaitre M, Ternynck C, Wallet H, Cazaubiel M, Labreuche J, Subtil D, Vambergue A. HbA1c at the time of testing for gestational diabetes identifies women at risk for pregnancy complications. Diabetes Metab. 2022;48(3):101313. Zhuang W, Lv J, Liang Q, Chen W, Zhang S, Sun X. Adverse effects of gestational diabetes-related risk factors on pregnancy outcomes and intervention measures. Exp Ther Med. 2020;20(4):3361-3367. Preciado L, Domínguez M, Morales J, Calle K, Campo M, Castro D. Perfil clínico de pacientes con diabetes gestacional e incidencia de complicaciones neonatales en un centro de referencia materno-fetal colombiano. Rev. chil. obstet. ginecol. 2020;85(3):210-220. González-González N, Vázquez P, Bartha J, Padrón E, Parache J. Estados de comportamiento fetal en gestantes con diabetes pregestacional y gestacional. Clínica e Investigación en Ginecología y Obstetricia. 2006;33(5):164-171. Oros M, Perejón D, Serna C, Siscart J, Àngel J, Sol J. Maternal and foetal complications of pregestational and gestational diabetes: a descriptive, retrospective cohort study. Scientific Reports. 2024;14(1):9017. Yang G, Dye T, Li D. Effects of pre-gestational diabetes mellitus and gestational diabetes mellitus on macrosomia and birth defects in Upstate New York. Diabetes Res Clin Pract. 2019;155:107811. Alberico S, Montico M, Barresi V, Monasta L, Businelli C, Soini V, et al. Multicentre Study Group on Mode of Delivery in Friuli Venezia Giulia. The role of gestational diabetes, pre-pregnancy body mass index and gestational weight gain on the risk of newborn macrosomia: results from a prospective multicentre study. BMC Pregnancy Childbirth. 2014;14:23. Vidal-Esteban A, de las Heras-Ibarra S, Domingo-Comeche L, García-Pimentel B, Lesmes-Moltó L, Rivero-Martín M. Frequency and type of complications of newborn children of mothers with gestational diabetes. Revista Mexicana de Pediatría. 2023;89(6):241-245. Mortier I, Blanc J, Tosello B, Gire C, Bretelle F, Carcopino X. Is gestational diabetes an independent risk factor of neonatal severe respiratory distress syndrome after 34 weeks of gestation? A prospective study. Arch Gynecol Obstet. 2017;296(6):1071-1077. Vanlaer Y, Minschart C, Vrolijk H, Van Crombrugge P, Moyson C, Verhaeghe J, et al. Impact of breastfeeding on risk of glucose intolerance in early postpartum after gestational diabetes. Front Endocrinol (Lausanne). 2024;15:1374682. Hokken-Koelega A, Van der Steen M, Boguszewski M, Cianfarani S, Dahlgren J, Horikawa R, et al. International consensus guideline on small for gestational age: etiology and management from infancy to early adulthood. Endocrine Reviews. 2023;44(3),539-565. Ibáñez-Correa L, Victoria S, Hurtado-Villa P. Prevalencia de cardiopatías congénitas en una cohorte de 54.193 nacimientos entre 2011-2017. Rev. Colomb. Cardiol. 2021;28(1):53-59. Bourdon G, Lenne X, Godart F, Storme L, Theis D, Subtil D, Bruandet A, Rakza T. Epidemiology of congenital heart defects in France from 2013 to 2022 using the PMSI-MCO (French Medical Information System Program in Medicine, Surgery, and Obstetrics) database. PLoS One. 2024;19(4):e0298234. Duarte V, Singh M. Genetic syndromes associated with congenital heart disease. Heart. 2024;110(20):1231-1237. Zhang T, Huang X, Zhao X, Wang W, Wen R, Gao S. Risks of specific congenital anomalies in offspring of women with diabetes: A systematic review and meta-analysis of population-based studies including over 80 million births. PLoS Med. 2022;19(2):e1003900. Narayanan M, Elkayam U, Naqvi T. Echocardiography in Pregnancy: Part 2. Curr Cardiol Rep. 2016;18(9):90. Yeh J, Berger S. Cardiac findings in infants of diabetic mothers. NeoReviews. 2015;16(11):e624-e630. Ullmo S, Vial Y, Di Bernardo S, Roth-Kleiner M, Mivelaz Y, Sekarski N, et al. Pathologic ventricular hypertrophy in the offspring of diabetic mothers: a retrospective study. Eur Heart J. 2007;28(11):1319-25. Moreno J.Nutrition in early life and the programming of adult disease: the first 1000 days. Nutrición Hospitalaria. 2016;33(4):337-337. Koletzko B, Brands B, Demmelmair H. Early Nutrition Programming Project. The Early Nutrition Programming Project (EARNEST): 5 y of successful multidisciplinary collaborative research. The American journal of clinical nutrition. 2011;94:S1749-S1753. Sweeting A, Ross G, Hyett J, Molyneaux L, Constantino M, Harding A, et al. Gestational diabetes mellitus in early pregnancy: evidence for poor pregnancy outcomes despite treatment. Diabetes care. 2016;39(1):75-81. Usami T, Yokoyama M, Ueno M, Iwama N, Sagawa N, et al. Comparison of pregnancy outcomes between women with early-onset and late-onset gestational diabetes in a retrospective multi-institutional study in Japan. J Diabetes Investig. 2020;11:216–222. |
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Africano-León, Martha Luciadd486b50-65fb-488a-828e-3ffca101b755-1Martínez-Vega, Ruth Aralí4174e65c-69b1-4547-8800-ba7207ee9305-1Arenas-Camacho, Laura Daniela369d2fc0-971e-425a-b109-4c9aeb43678e-1Chacón-Rey, Jorge Andres97c7ba79-6ac0-4d3f-893c-4dfe067e780d-1Hurtado-Sierra, Daniel Eduardo0ab07297-ca81-49bb-a79b-a03c011f7b50-1Giraldo-Castrillón, Yessica Maríaf698aa2a-3669-4ae7-883f-0e949bfc4792-12025-06-24T19:34:15Z2025-06-24T19:34:15Z2025-02-17DigitalLa Diabetes Mellitus Gestacional (DMG) es una problemática que impacta a Madres e Hijos con Desenlaces desafortunados y complicaciones a corto y largo plazo. Colombia tiene una prevalencia que oscila entre 0,34% y 2,03% (2021), Floridablanca del 4,9% (2014-2015) y Bucaramanga del 4,1% (2017). La prevalencia de obesidad según la encuesta nacional de salud en el 2015 fue de 13,3%, mayor que años previos. El objetivo fue determinar la Incidencia de los Desenlaces Adversos Agudos Neonatales en Hijos de Madres con DMG Concomitante con Sobrepeso u Obesidad cuyo parto fue atendido en la Clínica San Luis entre enero y diciembre/2022. Se trató de un Estudio Observacional, Descriptivo, Retrospectivo, Longitudinal y de fuente secundaria. Se revisaron las historias clínicas del binomio madre/hijo para extraer los antecedentes maternos, tratamiento, entre otros, así como el estado de salud del recién nacido. Se revisaron 5.282 historias, de las cuales 369 madres (374 hijos/5 partos gemelares) cumplieron los criterios de inclusión. Se realizó un análisis descriptivo de las características sociodemográficas y clínicas del binomio y un análisis exploratorio entre el tipo de tratamiento y los desenlaces neonatales y el control de la DMG. Se encontró una diferencia significativa en la frecuencia del desenlace prematurez (p=0,012) y la necesidad de ingreso a la unidad neonatal (p=0,017) por tipo de tratamiento, con mayor frecuencia para el grupo de dieta/insulina, y una mayor frecuencia de hipoglucemia neonatal (p=0,042) en el grupo de dieta/metformina. Además, se evidenció que el control glucémico de la DMG fue más frecuente en el grupo de tratamiento exclusivo con dieta (p=<0,001). Se pudo concluir que las maternas que son atendidas en la clínica tienen una prevalencia de DMG de 9,9% y que el desenlace neonatal más frecuente fue la ictericia (22,3%), seguida por el SDR (14,2%) y la macrosomía (11,8%).Gestational Diabetes Mellitus (GDM) is a problem that impacts Mothers and Children with unfortunate Outcomes and short- and long-term complications. Colombia has a prevalence ranging from 0.34% to 2.03% (2021), Floridablanca 4.9% (2014-2015) and Bucaramanga 4.1% (2017). The prevalence of obesity according to the national health survey in 2015 was 13.3%, higher than previous years. The objective was to determine the Incidence of Acute Adverse Neonatal Outcomes in Children of Mothers with GDM concomitant with overweight or obesity whose delivery was attended at the San Luis Clinic between January and December/2022. This was an Observational, Descriptive, Retrospective, Longitudinal and secondary source Study. The medical records of the mother/child pair were reviewed to extract maternal history, treatment, among others, as well as the health status of the newborn. 5,282 records were reviewed, of which 369 mothers (374 children/5 twin births) met the inclusion criteria. A descriptive analysis of the sociodemographic and clinical characteristics of the pair was performed, and an exploratory analysis was performed between the type of treatment and the neonatal outcomes and the control of GDM. A significant difference was found in the frequency of the outcome prematurity (p = 0.012) and the need for admission to the neonatal unit (p = 0.017) by type of treatment, with a higher frequency for the diet/insulin group, and a higher frequency of neonatal hypoglycemia (p = 0.042) in the diet/metformin group. Furthermore, it was found that glycemic control of GDM was more frequent in the diet-only treatment group (p=<0.001). It was concluded that maternal women treated at the clinic have a prevalence of GDM of 9.9% and that the most frequent neonatal outcome was jaundice (22.3%), followed by RDS (14.2%) and macrosomia (11.8%).EspecializaciónEspecialista en PediatríaUniversidad de SantanderIntroducción 19 Planteamiento del Problema 20 Descripción del Problema 20 Pregunta de Investigación 21 Justificación 22 Objetivos 24 Objetivo General 24 Objetivos Específicos 24 Marco Referencial 25 Definición de Diabetes Mellitus Gestacional 25 Definición de Sobrepeso y Obesidad Materna 26 Complicaciones Relacionadas con la DMG 27 Definición de los Eventos Adversos a Estudiar 29 Complicaciones Relacionadas con el Sobrepeso y la Obesidad Materna 30 El Papel del Tratamiento en el Control de la Enfermedad 31 Metodología 34 Tipo de Estudio 34 Población y Muestra 34 Criterios de Inclusión y Exclusión 34 Criterios de Inclusión 34 Criterios de Exclusión 35 Procedimientos 35 Análisis Estadístico 35 Consideraciones Éticas 36 Resultados 37 Características Demográficas y Clínicas de las Madres con DMG Concomitante con Sobrepeso u Obesidad y de los RN 38 Características Sociodemográficas y Clínicas de las Madres 38 Características de los Recién Nacidos 43 Frecuencia y Duración de la Hospitalización de los RN 46 Incidencia Acumulada de los Desenlaces Adversos Fetales y Neonatales Agudos 48 Desenlaces Neonatales Agudos y Control de la DMG Respecto al Tipo de Tratamiento que Recibió la Madre 51 Discusión 55 Conclusiones 64 Limitaciones 65 Recomendaciones 66 Referencias Bibliográficas 6780 papplication/pdfapplication/mswordUniversidad de SantanderT 103.25 A726dRepositorio Digital Institucional Universidad de Santanderhttps://repositorio.udes.edu.cohttps://repositorio.udes.edu.co/handle/001/11895spaUniversidad de SantanderBucaramangaFacultad de Ciencias Médicas y de la SaludBucaramanga, ColombiaEspecialización en PediatríaEspaña-Dorado S, González-Dagua Y, Riascos-Melo J, Ortiz-Martínez R, Chagüendo-García J. 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