Background: Gestational diabetes mellitus (GDM) is a common pregnancy-related metabolic disorder associated with adverse maternal and fetal outcomes. Recent research has highlighted the potential role of the oral microbiome in the pathophysiology of various systemic conditions, including diabetes mellitus. However, the impact of GDM on the maternal oral microbiome remains relatively understudied. Understanding alterations in the oral microbiome during pregnancy complicated by GDM could provide valuable insights into the mechanistic links between systemic metabolic disorders and oral health. Objective: The objective of this scoping review was to comprehensively examine the existing literature on the relationship between GDM and maternal oral microbiome composition and diversity. The review sought to identify the microbial changes associated with GDM and explore their potential implications for maternal oral health and pregnancy outcomes. Design: Following PRISMA-ScR guidelines, a systematic search of electronic databases, including “Pubmed” and “Web of Science,” was conducted to identify relevant studies investigating the impact of GDM on the maternal oral microbiome. Eligible studies included those examining microbial diversity, abundance, and composition in pregnant women with GDM and their neonates. Data synthesis involved summarizing key findings and identifying patterns across studies. Results: A total of eight primary studies were identified and included in the scoping review. These studies employed various methodologies, including observational reports, longitudinal analyses, and cohort studies, to investigate the relationship between GDM and the maternal oral microbiome. Findings from these studies revealed distinct alterations in oral microbial profiles among neonates and pregnant women with GDM compared to healthy controls. These alterations encompassed shifts in microbial diversity, abundance, and composition, suggesting potential biomarkers or indicators of GDM status within the oral microbiome. Longitudinal analyses further elucidated dynamic changes in the oral microbiota throughout pregnancy and postpartum, underscoring the temporal nature of these associations. Conclusions: The synthesis of evidence from the scoping review highlights significant associations between GDM and alterations in the maternal oral microbiome. While these findings imply a correlation between GDM and oral microbial changes, causality cannot be directly inferred. Further research is warranted to decipher the underlying mechanisms driving these associations and to explore their potential implications for maternal oral health and pregnancy outcomes. Nonetheless, the insights gleaned from this review underscore the importance of integrating oral health assessments into routine prenatal care protocols for gestational diabetic individuals. By doing so, healthcare providers can enhance risk stratification, early detection, and management of GDM, ultimately improving maternal and neonatal health outcomes.

Der Gestationsdiabetes betrifft etwa 5 von 100 Schwangeren. In unserer prospektiven, randomisierten Studie mit Crossover-Design untersuchten wir den Einfluß der Kohlenhydrataufnahme auf den Glukosestoffwechsel Schwangerer. 18 Gestationsdiabetikerinnen, 9 Frauen mit eingeschränkter Glukosetoleranz und 25 Kontrollen haben jeweils eine Woche eine kohlenhydratarme (35 Energieprozent) und eine kohlenhydratreiche (55 Energieprozent) Diät durchgeführt. Auswirkungen wurden anhand des konventionellen BZTPs und des kontinuierlich messenden Glukosesensors CGMS® untersucht. Die KH-Aufnahme wurde mittels einer Ernährungsberatung deutlich beeinflußt, und lag bei 39 % in der KH-reduzierten, und bei 49 % in der KH-reichen Woche. Nach DDG-Kriterien hatte der KH-Anteil bei keiner Gruppe einen signifikanten Einfluß bezüglich der Insulinpflicht. Dagegen waren der BZTP-Mittelwert und die AUC (area under the curve des CGMS®) der GDMs und der Kontrollen signifikant niedriger in der KH-armen Woche. In dieser Woche nahmen die Probandinnen auch eine niedrigere Energiemenge zu sich. Bei einer selektierten Untergruppe konnten wir diesen Einfluß ausgrenzen, und für die Kontrollgruppe eine signifikante Erniedrigung bezüglich der BZTP-Mediane und der AUCs nachweisen. Diese Beobachtungen belegen, daß ein höherer Kohlenhydratanteil mit erhöhten Blutzuckerwerten assoziiert ist. Außerdem wurde ein größerer Einfluß einer kohlenhydratarmen Ernährung auf die postprandialen als auf die Nüchternwerte festgestellt. Wegen der Auswirkungen auf das fetale Wachstum soll man bei Gestationsdiabetikerinnen eine kohlenhydratarme Ernährung empfehlen. / Gestational diabetes affects about 5 % of pregnancies. In our randomized prospective study with crossover design we examined the influence of carbohydrate intake on the glucose metabolism of pregnant women. 18 women with gestational diabetes, 9 with impaired glucose tolerance and 25 controls were put on a low (35 energy %) carbohydrate diet for one week and a high (55 energy %) carbohydrate diet for another. Blood glucose levels were recorded by self-monitoring and with a continuous glucose monitoring sensor (CGMS ®). Carbohydrate intake was strongly influenced by dietary advice, amounting to 39% into the low carbohydrate and 49% in the high carbohydrate week. According to DDG criteria, carbohydrate intake had no significant influence on insulin requirements. In contrast, mean blood glucose levels and the AUC (area under of the curve of the CGMS ®) were significantly lower for both gestational diabetics and controls in the low carbohydrate week. During this week, the average caloric intake was also reduced. We could exclude this influence for a selected subgroup, in which the controls displayed a significant reduction in median glucose levels and the AUCs. We could thus show that a higher carbohydrate content is associated with raised blood glucose levels. Furthermore, the influence of a low carbohydrate diet was greater on postprandial than on fasting levels. Because of the effects on fetal growth, one should recommend a low carbohydrate diet for gestational diabetics.

Abstract A low level of physical activity and poor physical fitness are important risk factors of chronic non-communicable diseases and all-cause mortality. Much of the risk of these diseases originates in fetal life. The associations of early-life determinants with physical activity and fitness later in life are as yet not well studied. The aim of this work was to investigate early-life factors as predictors of physical activity and fitness in adolescence and young adulthood. We assessed a wide range of parental and pregnancy-related factors in 16-year-old adolescent participants of the Northern Finland Birth Cohort 1986 (n=7,344), and focused on the long-term consequences of preterm birth in the 23-year-old adult participants of the ESTER study (n=1,161). Prenatal and parental predictors of low physical activity and cardiorespiratory fitness in adolescence included high gestational age-related birth weight as well as parental overweight or obesity. Also, both short and long gestational lengths were associated with lower physical activity, and maternal gestational diabetes mellitus and smoking during pregnancy were associated with lower cardiorespiratory fitness. Young adults born before 34 weeks of gestation reported substantially less leisure-time physical activity than those born at term, although this was not detected by accelerometer measurement. Those born preterm had lower muscular fitness, as individuals born before 37 weeks were able to perform fewer modified push-ups, and those born before 34 weeks had lower handgrip strength, but no difference was observed in cardiorespiratory fitness. Based on questionnaire data, young adults born before 34 weeks perceived themselves to be less fit than their term-born peers. Most individuals exposed to preterm birth or maternal gestational disorders are relatively healthy when reaching adulthood. However, their lower levels of physical activity and physical fitness compared with their peers born at term may contribute to a higher risk of chronic non-communicable diseases in later life. Finding physical activities that are suitable for each individual is essential to promote well-being and health and diminish the increased disease risk later in life. / Tiivistelmä Vähäinen fyysinen aktiivisuus ja heikko fyysinen kunto ovat merkittäviä kroonisten sairauksien ja ennenaikaisen kuoleman riskitekijöitä. Jo sikiökautisten tekijöiden tiedetään vaikuttavan syntyvän lapsen kroonisten sairauksien riskiin myöhemmin elämässä, mutta elämän varhaisvaiheen tekijöiden yhteyttä myöhempään fyysiseen aktiivisuuteen ja kuntoon on tutkittu verrattain vähän. Väitöstutkimuksen tavoitteena oli selvittää elämän varhaisvaiheen tekijöiden yhteyttä fyysiseen aktiivisuuteen ja kuntoon nuoruusiässä ja nuorena aikuisena. Tarkastelimme useiden vanhempiin ja raskausaikaan liittyvien tekijöiden vaikutuksia Pohjois-Suomen syntymäkohortti 1986 16-vuotistutkimuksessa (n=7344) ja keskityimme ennenaikaisen syntymän pitkäaikaisvaikutuksiin ESTER-tutkimuksen 23-vuotiaiden nuorten aikuisten aineistossa (n=1161). Tutkimustulostemme mukaan raskauden kestoon suhteutettu suuri syntymäpaino sekä vanhempien ylipaino tai lihavuus ennustivat vähäisempää liikunta-aktiivisuutta ja heikompaa kestävyyskuntoa nuoruusiässä. Sekä keskimääräistä lyhyempi että pidempi raskaudenkesto olivat yhteydessä vähäisempään liikunta-aktiivisuuteen ja äidin raskausdiabetes ja tupakointi raskauden aikana puolestaan heikompaan kestävyyskuntoon. Alle 34-viikkoisena syntyneet raportoivat liikkuvansa nuorena aikuisena vapaa-aikanaan huomattavasti vähemmän kuin täysiaikaisena syntyneet, vaikka eroa ei kiihtyvyysantureilla mitattuna fyysisessä aktiivisuudessa havaittukaan. Verrattuna täysiaikaisena syntyneisiin, ennenaikaisesti syntyneillä aikuisilla oli heikompi lihaskunto etunojapunnerrustestillä mitattuna ja hyvin ennenaikaisesti syntyneillä käden puristusvoima oli heikompi. Kestävyyskunnossa ei havaittu eroja. Hyvin ennenaikaisesti syntyneet myös arvioivat fyysisen kuntonsa huonommaksi kuin täysiaikaisena syntyneet ikätoverinsa. Vaikka valtaosa ennenaikaisena syntyneistä ja äidin raskaudenaikaisille sairauksille altistuneista on aikuisena varsin terveitä, liikunnan vähäisyys ja heikko fyysinen kunto voivat lisätä kroonisten sairauksien riskiä myöhemmin elämässä. Siksi tähän ryhmään kuuluvia tulisi erityisesti auttaa löytämään itselleen sopivia liikuntamuotoja hyvinvoinnin ja terveyden edistämiseksi ja siten myöhempien sairauksien ennaltaehkäisemiseksi.

L'intégration du traitement et de la prévention des maladies chroniques non transmissibles (MNT) au sein des soins de santé primaires représente le principal défi à venir pour la santé publique et les systèmes de santé dans les pays à faible et moyen revenu comme l’Afrique du Sud. Il constitue le principal objectif de cette thèse. L’expérience de l'intégration de la prévention de la transmission du VIH de la mère à l'enfant (PTME) dans les soins de santé primaires (SSP) peut apporter des leçons importantes pour l'intégration de la prévention du diabète chez les femmes souffrant de diabète gestationnel récent (DSG) dans les SSP. Il a été estimé que le DSG touche plus de 9,1 % des grossesses en 2018 en Afrique du Sud. Le DSG augmente le risque de développer ultérieurement du diabète de type 2 (DT2). Le DSG multiplie par plus de 7 le risque de développer un DT2 ainsi que les risques de troubles métaboliques pour les bébés des femmes qui en sont atteintes. Cette thèse explore comment appliquer les leçons tirées de l’intégration de la PTME pour intégrer le dépistage du DSG et les initiatives de prévention du DT2 dans les soins de santé primaires de routine en Afrique du Sud. Le cadre conceptuel adapté pour cette thèse permet ainsi de comprendre les aspects de l’intégration au niveau du patient et du système de santé, englobant les contextes, les mécanismes et la mise en œuvre de l’intégration d’interventions préventives dans les services existants. L'étude s'inscrit dans le cadre du projet IINDIAGO, « Intervention intégrée du système de santé visant à réduire les risques de diabète de type 2 chez les femmes défavorisées après un diabète gestationnel en Afrique du Sud ». La thèse présente d’abord une revue narrative de l’impact de la PTME sur les services et les systèmes de soins de santé en Afrique subsaharienne (Article 1). Les résultats de cette revue montrent que la PTME a eu l’impact positif et négatif sur d’autres services de soins de santé et que son intégration dans les systèmes de santé est de plus en plus privilégiée. L’article 2 est une étude qualitative analysant l’histoire et l’expérience locales de l’intégration de la PTME dans les SSP de routine en Afrique du Sud de différents points de vue. Bien qu’elle ait constaté un fort soutien en faveur de l’intégration parmi tous les répondants, cette étude a fait état de multiples obstacles à la pleine intégration de la PTME dans les SSP, le post-partum en particulier. Les articles 3 et 4 ont utilisé les méthodes mixtes et révélé que l’intégration des services dans les SSP de routine, à base communautaire, pour dépister universellement le DSG et pour prévenir ou retarder le DT2 après le DSG, était perçue comme faisable, acceptable et nécessaire de toute urgence en Afrique du Sud. L’article 6 (dont le protocole est l’article 5) présentait une revue systématique et une méta-analyse sur la prise en charge intégrée du DSG et du DT2 dans le contexte de la multimorbidité en Afrique. Les 13 études incluses dans cette étude ont montré que la gestion intégrée du DSG et du DT2 dans le cadre de la multimorbidité était mise en œuvre avec succès, mais qu’elle nécessitait une formation et une supervision adéquates des infirmières, et la fourniture d’équipements et de médicaments additionnels au sein des systèmes de santé nationaux en Afrique. Les conclusions de cette thèse suggèrent que, bien qu’elle n’ait pas toujours été retenue, en raison de défis structurels et opérationnels, l’intégration complète plutôt que partielle des services de santé est considérée comme souhaitable et réalisable par les femmes, les travailleurs de la santé, les gestionnaires et les experts. L’intégration complète pourrait être idéale pour dépister, diagnostiquer et soigner les maladies chroniques, y compris le DSG et le DT2, au sein des SSP de routine et selon l’approche de la PTME dont les leçons d’intégration n’ont pas été adaptées à ce prochain défi de santé publique. / Integrating chronic, non-communicable diseases (NCDs) and their prevention into primary health care is the next major challenge for public health and health systems in low and middle-income countries like South Africa and is the primary focus of this thesis. The experience of integration of Prevention of Mother-to-Child Transmission (PMTCT) of HIV into primary health care (PHC) may have important lessons for integrating prevention of diabetes among women with recent gestational diabetes (GDM) into PHC. GDM was estimated to affect more than 9.1% of pregnancies in 2018 in South Africa. GDM increases the risk of developing subsequent type 2 diabetes (T2DM) more than 7-fold as well as increasing the risks of metabolic disorders for the babies of women who had GDM. This thesis conducted a systematised narrative synthesis, a systematic review and a convergent mixed methods study using primarily qualitative methods in South Africa (focus on Cape Town, Western Cape) to explore how to apply lessons from PMTCT integration in order to integrate GDM screening and T2DM prevention initiatives into routine PHC in South Africa. The adapted conceptual framework for this thesis enables to understand both patient-level and health system-level aspects of integration and encompassing the contexts, mechanisms and implementation for integrating preventive interventions in the existing services. The study was nested in the IINDIAGO project, “Integrated health system intervention aimed at reducing type 2 diabetes risks in disadvantaged women after gestational diabetes in South Africa”. The thesis first presents a narrative review of the impact of PMTCT on health care services and systems in sub-Saharan Africa (Paper 1). This review findings show that PMTCT has had positive and negative impacts on other health care services and that its integration into health systems is increasingly favored. Paper 2 qualitatively documented the local history and experience of PMTCT integration into routine PHC in South Africa from different perspectives. Though it found strong support for integration among all respondents (N=20), this study reported multiple barriers for the full integration of PMTCT into PHC, especially in postpartum. Papers 3 and 4 used mixed methods and highlighted that integrating services within routine, community-based PHC to universally screen GDM and to prevent or delay of T2DM after GDM, was perceived as feasible, acceptable and urgently needed in South Africa – but that it is not currently occurring at a satisfactory level, despite international and national guidelines. The fifth article is a published protocol for Paper 6, a systematic review and meta-analysis on the integrated management of GDM and T2DM in the context of multimorbidity in Africa. This was a study in which all 13 included studies showed that integrated management of GDM and T2DM within multimorbidity was successfully implemented but it required adequate training and supervision of nurses, provision of additional equipment and drugs to the existing resources within national health systems in Africa. This thesis concludes that although not always opted for, due to structural and operational challenges, the full instead of partial integration of health services to screen, diagnose and care for chronic diseases including GDM and T2DM into routine PHC, following the PMTCT approach, was seen as both desirable and feasible by women, health workers, managers, and experts. However, the lessons learned through the history of PMTCT and its integration have not been adapted to this next public health challenge.

Identification of biomarkers involved in the pathophysiology of gestational diabetes mellitus ABSTRACT Gestational diabetes mellitus is a disorder of glucose metabolism that occurs in pregnancy and resolves after delivery. Increasing production of pregnancy-related hormones leads to insulin resistance which is not adequately compensated by increased insulin secretion. Since obesity is an important risk factor for gestational diabetes and is also associated with adipose tissue dysfunction and increased peripheral insulin resistance, the question arises as to what extent is the adipose tissue involved in the development of gestational diabetes. The first part of the thesis focuses on the identification of changes in plasma concentration and mRNA expression of adipokines fetuin A, fetuin B and FGF21. In our study we did not show that the presence of gestational diabetes significantly influenced the plasma concentration of fetuin A, fetuin B and FGF21 during pregnancy. An important finding was that women who had pregnancy complicated with gestational diabetes had a significantly higher concentration of FGF21 several months after delivery in comparison to healthy pregnant women. We have been able to demonstrate the production of fetuin A in the placenta and fetuin B in perineal and subcutaneous tissue. However,...

Sweden's maternal and childcare services have received recognition for maintaining high standards and employing effective risk-reduction strategies, leading to improved childbirth outcomes. However, these services face contemporary challenges exacerbated by evolving public health dynamics, including the increasing prevalence of obesity among Swedish adults, which mirrors trends in maternal healthcare and poses significant risks during pregnancy. Two significant risks during pregnancy are gestational diabetes mellitus (GDM) and preeclampsia. The rise in these pathophysiological conditions emphasizes the necessity for specialized maternal care approaches. In response, there is growing interest in utilizing technological innovations like glucose and blood pressure sensors for enhanced monitoring and proactive healthcare solutions during pregnancy.  This thesis investigates the intersection of maternal healthcare, technological advancements, and public health challenges in Sweden, aiming to identify innovative approaches to maternal care and explore the potential of glucose and blood pressure sensors in improving outcomes. To achieve it, an extensive literature review established a robust foundation, focusing on women's and maternity care trends and the impact of BMI on pregnancy outcomes. Interviews with healthcare professionals from diverse fields provided further insights, leading to an in-depth cause analysis and technology assessment. Subsequently, a mockup was developed based on the gathered information, utilizing JavaScript for program development and incorporating user feedback. Real-world data acquisition was explored using APIs, particularly Dexcom, for glucose monitoring. The design process employed Figma, ensuring visual appeal and functional integration, followed by comprehensive evaluation involving functional, usability, and compatibility testing to refine the mockup interface in alignment with stakeholder expectations.  The results of this study reveal two primary insights into maternal healthcare enhancement: Firstly, through a comprehensive literature review and stakeholder interviews, key challenges and potential solutions were identified, emphasizing the importance of interdisciplinary collaboration. Secondly, developing and evaluating a mockup integrating sensor technology demonstrated promising prospects for real-time monitoring and management, highlighting the potential for improving maternal health outcomes. These findings underscore the importance of integrating self-monitoring technology into maternal healthcare to enhance monitoring capabilities and address contemporary challenges in pregnancy care. / Sveriges mödra- och barnavårdstjänster har fått erkännande för att upprätthålla höga standarder och använda effektiva riskminskningsstrategier, vilket har lett till förbättrade förlossningsresultat. Emellertid möter dessa tjänster samtida utmaningar förvärrade av utvecklande folkhälsodynamik, inklusive den ökande förekomsten av fetma bland svenska vuxna, vilket speglar trender inom mödrahälsovård och innebär betydande risker under graviditeten. Två av dessa risker är graviditetsdiabetes mellitus och preeklampsi. Ökningen av dessa patofysiologiska tillstånd understryker behovet av nyanserade mödravårdsmetoder. Som svar finns det ett växande intresse för att använda teknologiska innovationer som glukos- och blodtryckssensorer för förbättrad övervakning och proaktiva hälsolösningar under graviditeten. Denna avhandling undersöker korsningen mellan mödrahälsovård, tekniska framsteg och folkhälsoutmaningar i Sverige, med målet att identifiera innovativa angreppssätt för mödraomsorg och utforska potentialen hos glukos- och blodtryckssensorer för att förbättra resultat.  För att uppnå detta etablerades en gedigen litteraturgenomgång som fokuserade på trender inom kvinnors och mödravård samt BMI:s påverkan på graviditetsresultat. Intervjuer med vårdpersonal från olika områden gav ytterligare insikter, vilket ledde till en djupgående orsaksanalys och teknisk bedömning. Därefter utvecklades en prototyp baserad på den insamlade informationen, med användning av JavaScript för programutveckling och inkorporering av användarfeedback. Verklig datainsamling utforskades med hjälp av API:er, särskilt Dexcom, för glukosövervakning. Designprocessen använde Figma för visuellt tilltalande och funktionell integration, följt av omfattande utvärderingar som involverade funktions-, användbarhets- och kompatibilitetstester för att förbättra prototypens gränssnitt i linje med intressenternas förväntningar.  Resultaten av denna studie belyser två primära insikter om förbättringar inom mödrahälsovård: För det första identifierades nyckelutmaningar och potentiella lösningar genom en omfattande litteraturgenomgång och intervjuer med intressenter, vilket betonar vikten av tvärvetenskapligt samarbete. För det andra visade utveckling och utvärdering av en prototyp som integrerar sensorteknik lovande framtidsutsikter för realtidsövervakning och hantering, vilket belyser potentialen för att förbättra mödrahälso-resultat. Dessa resultat understryker vikten av att integrera självövervakningsteknik i mödrahälsovård för att förbättra övervakningsmöjligheter och adressera samtida utmaningar inom graviditetsvård.

Ziel dieser vorliegenden, vergleichenden Literaturarbeit ist es, den heutigen Wissensstand in Bezug auf den Kohlenhydratstoffwechsel einer Frau darzustellen. Hierbei werden die physiologischen Veränderungen des Metabolismus zu verschiedenen Zeitpunkten im Leben einer Frau, begonnen mit der Kindheit und Pubertät, über Menstruation und Schwangerschaft bis hin zur Menopause, betrachtet und es werden die Ursachen und möglichen Mechanismen aufgezeigt, die zu Abweichungen der Insulinresistenz und der Insulinsekretion und damit möglicherweise zu einer Glukoseintoleranz bzw. einem Typ-2 Diabetes mellitus führen können. Der Kohlenhydratstoffwechsel wird nicht nur bezüglich der physiologischen, sondern auch in bezug auf die iatrogen verursachten Veränderungen, d.h. unter oraler hormonaler Kontrazeption, unter Hormonersatztherapie im Klimakterium, sowie hinsichtlich bestimmter Pathologien, wie dem zur Infertilität führenden polyzystischem Ovarsyndrom oder dem Gestationsdiabetes, untersucht. Ergebnis: Es scheint eine starke Verknüpfung zwischen dem weiblichen Reproduktionssystem und dem Kohlenhydratstoffwechsel zu geben, deren Interaktion von den unterschiedlichsten Faktoren beeinflusst wird. Der Frauenarzt sollte sich bei der Verschreibung hormoneller Kontrazeptiva, der Hormonersatztherapie und im Besonderen bei der Therapie des polyzystischen Ovarsyndroms sowie bei der Untersuchung seiner Patientinnen bewusst sein, dass verschiedene Lebensphasen, wie Pubertät, Schwangerschaft und Klimakterium und die damit verknüpften Veränderungen des Reproduktionssystems und der Sexualhormone auch deutliche metabolische Veränderungen nach sich ziehen können. Besonders eine erhöhte Insulinresistenz, die mit einer gesteigerten Insulinsekretion einhergeht, muss bedacht werden. Nicht nur das Syndrom X, eine Zusammenfassung von metabolischen Abnormitäten (Dyslipidämie, Insulinresistenz, Adipositas, Hypertonie), die mit einem deutlich erhöhten Risiko kardiovaskulärer Krankheiten und besonders der Atherosklerose einhergehen, sondern die daraus folgende steigende Prävalenz von Typ-2 Diabetes mellitus und das stark vermehrte Auftreten von Adipositas verlangen nach einer fachübergreifenden Zusammenarbeit zwischen Frauenärzten und Internisten. / The aim of this comparative review is to reveal the current standard of knowledge concerning carbohydrate metabolism in women. The study demonstrates the physiological changes in metabolism at various stages in a female life, from childhood and puberty, through menstruation and pregnancy and ending with the menopause, whilst also evaluating different causes and possible mechanisms that lead to aberrance in insulin resistance and insulin secretion and thereby potentially to glucose intolerance and/or type 2 Diabetes mellitus. In addition to presenting physiological alterations in glucose metabolism, this work also analyses changes generated by iatrogenic treatment such as oral contraceptives and hormone replacement therapy, as well as those caused by different pathologies like polycystic ovary syndrome or gestational diabetes. The results indicate a strong correlation between the female reproduction system and the carbohydrate metabolism. The interaction is influenced by the many very different factors. Before prescribing oral contraceptives, hormone replacement therapy in climacteric (especially during the treatment of infertility in PCOS), or examining patients, the gynaecologist needs to be aware of the fact that different phases in life along with sex steroids and connected changes in the reproductive system, might lead to severe metabolic diversifications. Special attention should be paid to an increased insulin resistance, associated with an augmentation in insulin secretion. Not only the metabolic syndrome, the simultaneous appearance of metabolic abnormalities (dyslipidaemia, insulin resistance, adiposity, hypertonia), which holds a higher risk of cardiovascular diseases, especially arteriosclerosis, but also the consequential increased prevalence of type 2 diabetes mellitus and the highly increased prevalence of adiposity, demand for a multidisciplinary collaboration between gynaecologists and internists.

Text in English with abstracts and keywords in English and Setswana / Aim: The purpose of the research was to determine the magnitude and factors associated with gestational diabetes mellitus (GDM), and to explore the experiences of gynaecologists/obstetricians and midwives in the monitoring and prevention of GDM- related adverse maternal outcomes in order to propose best practice guidelines which may be implemented to overcome the problem. Methods: A concurrent mixed methods design was used. Participants for the quantitative study were selected using systematic random sampling, with purposive sampling being used for the qualitative part of the study. A total of 2000 medical records were reviewed using a checklist, in addition to which 7 gynaecologists/obstetricians and 12 midwives were interviewed using an in-depth interview guide. Descriptive and inferential statistics were used for the quantitative part, while Colaizzi’s manual qualitative data analysis method wasused for the qualitative part of the study. Findings: The magnitude of GDM was found to be 2.2%. Age and family history of diabetes mellitus were found to be factors associated with GDM (at p < 0.001). Other factors such as obesity, previous GDM, previous history of fetal macrosomia and multiple gestations were identified by respondents as factors related with GDM. In addition, the study explored the experiences of health professionals (HPs) in the monitoring and prevention of adverse maternal outcomes related to GDM, with the results showing some differences in screening and diagnostic techniques. It was also shown that lifestyle modification (physical exercise, diet management) and medication were utilised for managing women with GDM. In this regard, all the HPs agreed that creating awareness is the best intervention for preventing GDM as well as its adverse maternal outcomes. Conclusions: The magnitude of GDM is increasing, and much needs to be done to draw attention to the burden that GDM places on the health of pregnant women and the public. Since GDM is not considered a public health problem, little is being done to monitor the condition and its adverse maternal outcomes. It is hoped that the best practice guidelines developed from this research study may assist in reducing the adverse maternal outcomes of GDM in Ethiopia / Maikaelelo: Lebaka la patlisiso e ne e le go tlhotlhomisa go nna teng le mabaka a a golaganeng le bolwetsi jwa sukiri jwa baimana (GDM), le go tlhotlhomisa maitemogelo a dingaka tsa malwetsi a basadi (gynaeologists/ obstetricians) le babelegisi mo go tlhokomeleng le go thibeleng ditlamorago tse di maswe mo baimaneng tse di amanang le GDM gore go tshitshinngwe dintlhakaelo tse di gaisang tse di ka diragadiwang go fenya bothata. Mekgwa: Go dirisitswe thadiso ya mekgwa e e tlhakantsweng. Banni-le-seabe ba thutopatlisiso e e lebelelang dipalopalo ba ne ba tlhophiwa go diriswa go tlhopha sampole ka go se latele thulaganyo, mme go tlhopha sampole ka maikaelelo go ne ga diriswa mo karolong ya thutopatlisiso e e lebelelang mabaka. Go sekasekilwe palogotlhe ya direkoto tsa kalafi tse 2 000 go diriswa lenanetshekatsheko, mme mo godimo ga moo, go ne ga nna le dipotsolotso le dingaka tsa malwetsi a basadi di le supa le babelegisi ba le 12 go diriswa kaedi ya dipotsolotso tse di tseneletseng. Dipalopalo tse di tlhalosang le tse go sweditsweng ka tsona di ne tsa diriswa mo karolong ya dipalopalo ya thutopatlisiso, fa go dirisitswe mokgwa wa ga Colaizi wa tokololo ya data ya mabaka mo karolong e e lebelelang mabaka. Diphitlhelelo: Go nna teng ga GDM go ne ga fitlhelwa e le 2.2%. Dingwaga le hisetori ya bolwetsi jwa sukiri ya baimana mo lelapeng di fitlhetswe e le dintlha tse di golaganeng le GDM (ka p < 0.001). Dintlha dingwe, jaaka go nona phetelela, GDM mo nakong e e fetileng, go nna teng ga macrosomia ya masea mo nakong e e fetileng le boimana jwa masea a feta bongwe di ne tsa supiwa ke batsibogi jaaka dintlha tse di golaganeng le GDM. Go tlaleletsa foo, thuto e ne ya sekaseka maitemogelo a baporofešenale ba boitekanelo (HPs) mo tlhokomelong le thibelo ya ditlamorago tse di sa siamang mo baimaneng tse di golaganeng le GDM, mme dipholo di bontshitse dipharologano dingwe mo dithekeniking tsa go sekirina le go phekola. Go bonagetse gape gore phetolo ya mokgwa wa botshelo (katiso ya mmele, tsamaiso ya mokgwa wa go ja) le kalafi di ne tsa diriswa go laola bolwetsi jwa basadi ba ba nang le GDM. Mo lebakeng le, baporofešenale botlhe ba boitekanelo ba ne ba dumelana gore go dira temoso ke tsereganyo e e gaisang ya go thibela GDM ga mmogo le ditlamorago tsa yona tse di sa siamang mo baimaneng. Ditshwetso: Go nna teng ga GDM go a oketsega, mme go tshwanetse go dirwa go le gontsi go lemosa ka mokgweleo o bolwetse jono bo o bayang mo boitekanelong jwa baimana le setšhaba. Ka ntlha ya gore GDM ga e kaiwe jaaka bothata jwa boitekanelo jwa setšhaba, ga go dirwe go le kalo go tlhokomela bolwetsi le ditlamorago tsa jona tse di sa siamang mo baimaneng. Go solofelwa gore dintlhakaelo tsa tiriso e e gaisang tse di dirilweng mo thutopatlisisong eno di ka thusa go fokotsa ditlamorago tse di sa siamang tsa GDM mo baimaneng kwa Ethiopia. / Health Studies / D. Litt. et Phil. (Public Health)

<p>Uvod: Vi&scaron;eplodne trudnoće se javljaju u 1,5% svih trudnoća nakon spontane koncepcije, dok nakon postupaka vantelesne oplodnje ovaj postotak u Evropi iznosi preko 20% uz velike varijacije među zemljama. U na&scaron;oj sredini, stopa vi&scaron;eplodnih trudnoća nakon postupaka vantelesne oplodnje iznosi daleko iznad 30%. Pojava hipertenzivnog sindroma u trudnoći, gestacijskog dijabetesa, operativnog zavr&scaron;avanja trudnoće, prevremenog porođaja, male porođajne telesne mase, neurolo&scaron;kih sekvela kod rođene dece i gotovo svih drugih komplikacija po majku i plod, kao i celokupno opterećenje zdravstvenog sistema vi&scaron;estruko su veći kod vi&scaron;eplodnih u odnosu na jednoplodne trudnoće i udeo navednih komplikacija raste sa brojem plodova. Sa druge strane deca iz postupaka vantelesne oplodnje čine i do 4,5% sve živorođene dece u pojedinim zemljama, &scaron;to uz činjenicu da infertilitet pogađa 16-18% parova u na&scaron;oj sredini daje ovoj pojavi posebnu dimenziju i činije i dru&scaron;tvenim problemom. Perinatalni ishodi trudnoća iz postupaka vantelesne oplodnje su u velikoj meri kompromitovani visokom stopom multiplih trudnoća, koje se danas smatraju komplikacijom, a ne uspehom postupaka vantelesne oplodnje. Jednoplodne trudnoće iz postupaka vantelesne oplodnje u većim studijama pokazuju diskretno slabije perinatalne ishode u odnosu na one spontano začete, dok kod vi&scaron;eplodnih trudnoća ova korelacija nije jasno izražena i dokumentovana, uz prisutnu dilemu da li je vi&scaron;eplodnost sama po sebi ili način koncepcije glavni problem u zapaženoj pojavi. Cilj rada: Uporediti perinatalne ishode vi&scaron;eplodnih trudnoća nastalih postupcima vantelesne oplodnje i spontano začetih kao i perinatalne ishode jednoplodnih i vi&scaron;eplodnih trudnoća iz postupaka vantelesne oplodnje. Pored navdenog cilj rada je i ukazati sveobuhvatnost navedenog problema i na moguća re&scaron;enja za smanjenje njihove učestalosti. Materijal i metode: Kombinacijom retrospektivne opservacione studije i prospektivne longitudinalne kohortne studije u periodu analizom perinatalnih ishoda pacijentkinja porođenih na Klinici za ginekologiju i aku&scaron;erstvo Kliničkog centra Vojvodine u periodu od od 01.01.2008. do 31.12.2010. godine, studija je analizirala i poredila perinatalne ishode kod 174 spontano začete vi&scaron;eplodne trudnoće, 163 vi&scaron;eplodne trudnoće nastale postupkom vantelesne oplodnje, kao i 155 jednoplodnih trudnoća začete postupkom vantelesne oplodnje. Analizirani parametric bili su telesna masa novorođenčeta, dostignuta gestacijska starost, vrednosti Apgar skora, učestalost hipertenzivnog sindroma kod majke i brojni drugi parametri perinatalnog ishoda. Uzeti od strane obučenih kliničara i uno&scaron;eni u posebno dizajniranu bazu podataka, rezultati su statistički analizirani u program JMP ver 9.0 (SAS publisher) uz kori&scaron;ćenje ANOVA analize za testiranje statističke značajnosti između srednjih vrednosti kontinuiranih varijabli, dok je statistička značajnost razlike učestalosti kategorijskih varijabli je određivana Pearsonovim &chi;2 testom. Rezultati: Jednoplodne ART trudnoće uz prosečnu starost od 33,5 godine, prosečnu gestacijsku starost na porođaju od 38,26 gn, udeo prevremenih porođaja od 12,9%, prosečnu telesnu masu od 3258 g, AS u prvom minutu od 8,35 i u petom minutu od 9,2, stopu carskog reza od 65,81%, udeo GDM-a od 7,1%, anemije od 41,94% i preeklampsije od 4,52%, ima sve relevantne parametre perinatalnog ishoda statistički značajno (p&lt;0.0001) superiornije od kako ART tako i non ART blizanačkih trudnoća. ART blizanačke trudnoće pokazale su prosečnu starost majke od 32,9 godina, prosečnu gestacijsku starost na porođaju od 35,6 gn, udeo prevremenih porođaja od 58,27%, prosečnu telesnu masu od 2374 g, AS u prvom minutu od 7,45 i u petom minutu od 8,65, stopu carskog reza od 83,7%, udeo GDM-a od 15,11%, anemije od 78,42% i preeklampsije od 12,23%, dok su non ART blizanačke trudnoće pokazale prosečnu starost majke od 28,8 godina, prosečnu gestacijsku starost na porođaju od 36,08 gn, udeo prevremenih porođaja od 49,71%, prosečnu telesnu masu od 2433 g, AS u prvom minutu od 7,75 i u petom minutu od 8,75, stopu carskog reza od 58,33%, udeo GDM-a od 7,02%, anemije od 67,84% i preeklampsije od 11,11%. Pored godina majke i udela carskog reza koji su bili vi&scaron;i u ART blizanačkim trudnoćama (&lt;0.0001), kao i blago veće pojavi poremećaja količine plodove vode (p=0,033), gotovo svi ostali pokazatelji toka i ishoda trudnoće bili su komparabilni u navedenim grupama. Diskusija i zaključak: Studija je pokazala da su tok i ishod vi&scaron;eplodnih trudnoća nastalih spontano i postupcima vantelesne oplodnje ekvivalentni u gotovo svim pokazateljima uz sličnu prosečnu telesnu masu i gestacijsku starost novorođenčadi, kao i da su svi navedeni parametri ovih vi&scaron;eplodnih trudnoća bez obzira na način koncepcije upadljivo i podjednako lo&scaron;iji u poređenju sa jednoplodnim trudnoćama iz postupka vantelesne oplodnje. Izuzimajući vi&scaron;eplodnost kao factor rizika deca iz postupaka vantelesne oplodnje su generalno zdrava. Sama vi&scaron;eplodnost, a ne način koncepcije predstavljaju problem, koje se sa pravom smatra najvećom komplikacijom vantelesne oplodnje. Dodatna analiza iskustava drugih zdravstvenih sistema ukazuje da jedino &scaron;iroka i sveobuhvatna implementacija strategije vraćanja samo jednog embriona (Single embryo transfer &ndash; SET) može da dovede do smanjivanje stope multiplih trudnoća nakon postupaka vantelesne oplodnje, i sledstvenih komplikacija, a bez ugrožavanja samog uspeha vantelesne oplodnje. Iskustva drugih zdravstvenih sistema ukazuju da je uspe&scaron;na implementacija SET-a jedino moguća uz angažovanje celog dru&scaron;tva, zajedno sa brojnim legislativnim merama iz domena nadzora, kontrole i finansiranja postupaka vantelesne oplodnje. Obim i način finansiranja postupaka vantelesne oplodnje od strane države (uz vi&scaron;e besplatnih poku&scaron;aja za infertilne parove) uz obaveznu upotrebu SET-a, i sistema krioprezervacije na osnovu primera iz prakse predstavlja ključ u borbi za smanjenje problema vi&scaron;eplodnih trudnoća nakon postupaka vantelesne oplodnje.</p> / <p>Introduction: Multiple pregnancies occur in 1.5% of all pregnancies after spontaneous conception and in more than 20 % of all pregnancies concieved after assisted reproductive technologies in Europe, with large variations between countries. In our setting, the rate of multiple pregnancies after the ART is well above 30%. The occurrence of hypertensive syndrome in pregnancy, gestational diabetes, operative delivery, premature birth, low birth weight, neurological and developmental impairment in children, and almost all the other complications for the mother and fetus, as well as the entire burden of the health system are several times higher in multiple pregnancies compared with singleton pregnancies. Incidence of&nbsp; forementioned complications rises with number of fetuses. On the other hand, children from in vitro fertilization procedures make up 4.5% of all live births in some countries, which together with the fact that infertility affects aproximately 16-18% of couples in our country gives an extra dimension to this phenomenon and makes it not just medical but wider social problem. Perinatal outcomes of pregnancies after assisted reproductive technologies (ART) are greatly compromised by the high rate of multiple pregnancies, which are now considered to be a complication rather than success of ART procedures. ART Singleton pregnancies have, in larger studies, show discretely lower perinatal outcomes compared with those conceived spontaneously, while for the multiple pregnancies, this correlation is not clearly expressed and documented. There remains dilemma whether multiplicity itself or the way of conception (ART vs. non ART) constitutes a major problem in the observed differences regarding perinatal outcome of ART pregnancies. Objective: To compare the perinatal outcomes of multiple pregnancies conceived by In vitro fertilization (IVF) and spontaneously and perinatal outcomes of IVF conceived singleton and multiple pregnancies. Additional aim of this thesis is to point out the complexity of this problem and offer possible solutions. Materials and Methods: Design of a study was a combination of retrospective and prospective observational longitudinal cohort study. Analysis included pregnancies which had delivery at the Department of Gynecology and Obstetrics, Clinical Center of Vojvodina in the period from 1.01.2008. to 31.12.2010. The study analyzed and compared the perinatal outcomes in 174 spontaneous conceived multiple pregnancies, 163 multiple pregnancies resulting from IVF procedures, and 155 singleton pregnancies conceived by IVF procedure. Analyzed parameters were newborns birth weight, gestational age at delivery, the value of the Apgar score, occurrence of hypertensive syndrome in pregnancy, gestational diabetes, as well as numerous parameters of perinatal outcome. Taken by trained clinicians and were entered into a specially designed database, the results were statistically analyzed in JMP ver 9.0 software (SAS publisher) using ANOVA analysis to test the statistical significance between the mean values of continuous variables, while the statistical significance of the difference in frequency of categorical variables was assessed by Pearsons &chi;2 test. Results: ART singleton pregnancies had an average mothers age of 33.5 years, the average gestational age at birth of 38.26 gestational weeks (gw), preterm delivery rate of 12.9%, average birth weight 3258 g, Apgar score (AS) in the first minute 8.35, and in the fifth minute 9.2, cesarean section rate 65.81%, Gestational diabetes (GDM) in 7.1% pregnancies, anemia occurred in 41.94% of pregnancies, while preeclampsia was observed in 4.52% of all pregnancies. All relevant parameters of perinatal outcome were significantly (p&lt;0.0001) superior to both ART and non-ART twin pregnancies. ART twin pregnancy showed the average mothers age of 32.9 years, the average gestational age at birth of 35.6 gw, the preterm delivery rate 58.27%, the average body weight newborns 2374 g, AS in the first minute of 7.45, and in the fifth minute of 8.65, the cesarean section rate of 83.7%, GDM in 15.11% of all pregnancies, anemia occurred in 78.42% and preeclampsia in 12.23% of pregnancies, while the non-ART twin pregnancy showed an average mothers age of 28.8 years, the average gestational age at birth of 36.08 gw, the preterm delivery rate of 49.71%, the average body weight of 2433 g, AS in the first minute of 7.75 in the fifth minute 8.75, the caesarian section rate of 58.33%, GDM-a occurred in 7.02%, anemia in 67.84% and preeclampsia in 11.11% of pregnancies. Except for maternal age and the caesarean section rate, which were significantly higher in ART twin pregnancies (p&lt;0.0001), as well as small increase in proportion of amniotic fluid volume disorders (p = 0.033), almost all other parameters of perinatal outcome of were comparable in these groups. Discussion and Conclusion: The study showed that the course and outcome of multiple pregnancies conceived spontaneous and after IVF procedures are equivalent in almost all parameters with similar average body weight and gestational age at birth, and that all these parameters of multiple pregnancies regardless of the conception mode are equally worse compared with singleton pregnancies from IVF procedures. With the exception of multiplicity as a risk factor children from in vitro fertilization procedures are generally healthy. Multiplicity itself and not the mode of conception presented a problem, which is rightly considered the major complication of IVF today. Additional analysis of the experiences of other health system indicates that only a broad and comprehensive implementation of strategy to return only one embryo (SET&ndash;single embryo transfer) can lead to a reduction of the rate of multiple pregnancies after IVF procedures, and the accompanying complications, without compromising IVF success. The experience of other health systems indicate that a successful implementation of SET is only possible with the involvement of the whole society, along with a number of legislative measures in the field of monitoring, control and reimbursement of assisted reproduction procedures. The scope and funding of an IVF procedures (with more free attempts for infertile couples, reimbursed by public health) with mandatory use of SET, and good cryopreservation programs are, based on examples in other countries who had successfully dealt with his problem, is the key in reducing the problem of multiple pregnancies after IVF procedures.</p>