Relação dos achados eletromiográficos dos músculos do assoalho pélvico com os níveis de relaxina ao longo da gestação e após o parto de mulheres com hiperglicemia gestacional e incontinência urinária específica da gestação
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2021-08-27
Autores
Prudencio, Caroline Baldini
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Universidade Estadual Paulista (Unesp)
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Introdução: A gestação é o evento no qual os músculos do assoalho pélvico (MAP) recebem importante sobrecarga. A ocorrência de alterações funcionais dos MAP durante e/ou após a gestação dependerá de diferentes fatores, sendo que dentre os principais estão o ganho de peso materno, aumento do volume uterino, alterações no alinhamento postural, comorbidades associadas à gestação e fatores hormonais. Adicionalmente, o peso do recém-nascido soma-se aos fatores de risco para desenvolvimento ou agravamento de disfunções no pós-parto. O Diabetes Mellitus Gestacional (DMG) é alteração patológica específica da gestação e que é rastreada pela primeira vez no decorrer do período gravídico. Preconiza-se pela American Diabetes Association (ADA) que entre a 24ª e a 28ª semana gestacional seja realizado o exame de glicemia de jejum e teste de tolerância oral a glicose. No âmbito das alterações musculares a ação da hiperglicemia gestacional (HG) foi documentada por estudos experimentais no tecido periuretral de ratas que demonstraram impacto similar quando induzido diabetes severo e moderado retratando alterações morfológicas nas fibras musculares uretrais, caracterizado por adelgaçamento, desorganização, além de atrofia muscular. No tecido musculoesquelético de gestantes estudos morfológicos demonstraram no reto abdominal alterações similares ao experimental. Além disso, outras estruturas também são acometidas pela hiperglicemia, uma vez que estudos clínicos e experimentais demonstraram alterações na composição da matriz extracelular, fibrose, alteração na ultraestrutura 49 como acúmulo de mitocôndrias, aumento de gotas de lipídios e acúmulo de grânulos de glicogênio no grupo diabético moderado prenhe. Todas estas modificações podem influenciar negativamente a funcionalidade dos MAP e ocasionar disfunções musculares do assoalho pélvico (DMAP), como por exemplo, a incontinência urinária (IU). Somado a este panorama existem as alterações hormonais gestacionais que também podem influenciar na capacidade funcional dos MAP. O hormônio relaxina, faz parte da superfamília da insulina e está relacionado à manutenção da gestação e com as principais adaptações gravídicas, principalmente, sobre o sistema cardiovascular e tecido conjuntivo. No tecido conjuntivo, a relaxina altera a densidade e quantidade de colágeno na matriz extracelular, além de aumentar o colágeno solúvel e diminuir o insolúvel, proporcionando a remodelação de um tecido mais firme para mais elástico. Há ainda a ação de enzimas degradadoras de colágeno que conferem características anti-fibrótica a este hormônio, processo que prepara a pelve para o processo do parto que resulta em frouxidão dos ligamentos, fáscias e sínfise púbica, com consequente interferência no sistema de suporte pélvico. Além disso, a relaxina aumenta a atividade de metaloproteinases no trato urinário o que pode diminuir a capacidade recuperação dos MAP após o parto. Isto se deve, provavelmente, porque os MAP dependem desses componentes para que o suporte ideal ocorra e garanta que sua função seja executada de maneira eficaz. A relação de dependência entre a integridade do tecido conjuntivo e a ação muscular em conjunto com a teoria de ação hormonal durante gestação ainda não está clara na literatura e traz dados conflitantes em relação ao aumento ou diminuição da relaxina e a presença de DMAP na gestação. A literatura demostra que gestantes com diagnóstico de diabetes clínico e DMG podem apresentar níveis de relaxina diminuídos ou aumentados em relação a gestantes não-diabéticas independente do trimestre. Fato que pode ser explicado pela 50 relaxina aumentar a ligação de insulina aos receptores de insulina nos adipócitos. Porém, o mecanismo deste aumento em sua concentração ainda não foi esclarecido e parece estar relacionado com ajustes da própria gestação complicada pelo diabete. Embora as temáticas gestação hiperglicêmica, IU e relaxina serem tratadas na literatura, os estudos apresentam os resultados separadamente e não há estudos que inter-relacionem os três fatores. Com objetivo de entender esta dinâmica, a presente tese é estruturada em 2 artigos que trarão maior conhecimento sobre a temática. Para tanto, dosagens séricas do hormônio relaxina foram realizadas analisadas. A incontinência urinária específica da gestação (IU-EG) e IU pós-parto foram avaliadas por instrumentos validados que mensuram a severidade e impacto da IU. A função dos MAP foi avaliada pela eletromiografia, exame recomendado pela International Continence Society (ICS) e International Urogynecological Association (IUGA), para registrar a atividade extracelular bioelétrica gerada pelas fibras musculares e, desta forma, inferir sobre o comportamento neuromuscular. Justificativa: O grupo de pesquisa Diamater Study Group empenhou-se em estudar nos últimos anos o efeito do DMG sobre os MAP. Barbosa et al. (2011) em seu estudo confirmou associação entre a DMG e a presença de baixa pressão de contração dos MAP dois anos após cesárea. Os estudos translacionais clínicos e experimentais identificaram alterações nas características das fibras musculares e matriz extracelular (MEC). Estes resultados corroboram com os resultados clínicos de que a IU-EG em gestação com DMG está associada à DMAP. Os temas relaxina, DMG e função dos MAP são abordados de modo individual, porém observa-se que eles têm pontos que convergem e que precisam ser investigados em associação. Não foram encontrados na literatura trabalhos que abordem o impacto do aumento nos níveis do hormônio relaxina sobre a função dos MAP em gestantes com DMG, indicando importante lacuna no 51 conhecimento sobre os fatores que interferem no desempenho dos MAP durante a gestação. Os resultados da presente tese poderão auxiliar no manejo e detecção de possíveis fatores de risco para DMAP e desta maneira planejar e propor condutas tanto de caráter minimizador, curativo ou preventivo. Artigo 1 Objetivos: 1) Comparar o padrão de ativação dos MAP entre mulheres com GDM e não-GDM entre 24-30 semanas de gestação até 18-24 meses pós-parto durante um teste clínico padrão. Métodos: 1) Trata-se de estudo de coorte prospectivo que avaliou as participantes em três momentos distintos: de 24-30 semanas de gestação (1º momento), 36-38 semanas de gestação (2º momento) e 18-24 meses após o parto (3º momento). Os principais critérios de inclusão foram: gestantes que no momento da avaliação estivessem com 24-30 semanas gestacionais, gravidez única sem IU prévia. O critério para composição dos 2 grupos de estudo foram as diretrizes propostas pela ADA, utilizando o teste oral de tolerância glicêmica de 75g (75g-TOTG), participantes que obtiveram níveis em jejum ≥92 mg / dL ou 1 hora ≥180 mg / dL ou 2 horas ≥153 mg / dL foram alocadas no grupo DMG. As participantes que apresentaram valores abaixo compuseram o grupo não-DMG. O recrutamento ocorreu no Centro de Pesquisa em Diabetes Perinatal da Faculdade de Medicina de Botucatu/UNESP/Brasil, entre 2015 e 2018. As participantes que aceitaram participar foram avaliadas com 24-30 semanas de gestação por questionário com dados pessoais, clínicos e histórico obstétrico e o índice de massa corporal (IMC) foi aferido. Na sequência, foi explicado sobre o exame funcional dos MAP e as participantes foram posicionadas na maca em decúbito dorsal e foi realizada a palpação digital dos MAP para confirmar que as participantes conseguiam entender o comando verbal de contração e relaxamento. Em seguida, foi realizado o preparo do exame eletromiográfico, por meio da introdução de sonda vaginal com dois eletrodos opostos de aço inoxidável (85 x 25 mm) posicionados em 52 ambas as paredes vaginais. O protocolo Glazer foi utilizado para padronizar as contrações: 60 segundos de repouso (pré-linha de base); contração fásica de 1 segundo (contração rápida) repetida por 5 vezes (5x), com 10 segundos de descanso entre as contrações; 10 segundos de contração tônica por 5x, com 10 segundos de descanso; e uma contração lenta sustentada por 60 segundos seguido de 60 segundos de repouso (pós-linha de base). Após a avaliação no 1º momento as participantes foram agendadas para a reavaliação no 2º momento e 3º momento, e os mesmos procedimentos foram realizados em cada etapa. Em relação a análise dos dados, as medidas foram realizadas no domínio do tempo por meio das medidas de root mean square (RMS), as quais predizem sobre a amplitude do sinal durante as diferentes tarefas do protocolo, através das variáveis média, pico e variabilidade do desvio padrão e de seu coeficiente de variação. Além disso, o comportamento do sinal em relação ao tempo entre o início da contração e o pico e do pico até o final da contração foram expressos em segundos. A taxa de ativação neural durante o início e o fim da contração e, também, antes e depois do pico foram avaliados. Com objetivo de visualizar o comportamento da contração durante todo o protocolo, foi realizado análise de wf-wavelets para comparar o formato das curvas entre os grupos em cada tarefa específica. Resultados: 1) Os dados demográficos e obstétricos foram homogeneidade entre os grupos. O grupo GDM mostrou durante as contrações Flick de 1 seg menores amplitudes no pós-parto. Além disso, embora o grupo DMG atingiu o pico de amplitude de forma semelhante ao não-GDM, eles demoram mais para retornar aos níveis basais. Durante as contrações sustentadas de 10 segundos, o grupo DMG manteve níveis mais baixos de ativação dos MAP do que o grupo não-DMG ao final da gestação e no pós-parto quando comparado ao grupo não-DMG. Conclusão: 1) Os resultados sugerem que o DMG prejudica a controle da ativação 53 do MAP durante as contrações rápidas (1-seg) e lentas (10-seg), sendo que estas alterações aparecem no final da gestação e se estendem até 2 anos após o parto. O comportamento motor encontrado pode ter influência sobre as DMAP e deve ser foco de futuros estudos mecanísticos e clínicos envolvendo a temática. Artigo 2 Objetivo: 2) Investigar os níveis de relaxina em mulheres com e sem DMG de acordo com status da incontinência urinária e função muscular do assoalho pélvico. Métodos: 2) Trata-se de estudo transversal que avaliou 282 gestantes em qualquer momento gestacional a partir da 24ª semana gestacional. Os principais critérios de inclusão foram: gestantes entre 24 até 38 semanas de gestação, primigesta ou secundigesta com parto cesárea anterior, gravidez de feto única e sem histórico de IU prévio a atual gestação. As participantes foram divididas em 2 grupos principais, não-DMG e DGM, de acordo com a presença de diabetes avaliado pelo TOTG-75g. Além disso, de acordo com sub-análises os grupos foram subdivididos de acordo com o status da continência urinária durante a gestação, sendo assim formado 4 subgrupos: não-DGM-C (não-DMG continente), não-DGM-IUEG (não-DMG incontinente), DGM-C (DMG continente), DGM-IUEG (DMG incontinente). O protocolo de avaliação seguiu a mesma sequência de avaliação do estudo anterior, foi administrado questionário com dados pessoais, clínicos e obstétricos e adicionou-se questionários validados no Brasil para avaliação da IU, sendo eles, o "International Consultation on Incontinence Questionnaire - Short Form" (ICIQ-SF) e o “Incontinence Severity Index” (ISI). Na sequência foram realizadas as mesmas instruções do artigo anterior em relação ao treinamento prévio da musculatura e foi performado a avaliação funcional do assoalho pélvico por meio da escala PERFECT, no qual foram coletados os dados de força, endurance e repetições de contrações rápidas (P,E,F). Resultados 2) As concentrações relaxina-2 foram significativamente menores em participantes com IUEG, tanto no grupo não- 54 DMG (p=,023) quanto no grupo DMG (p=,027), no entanto o grupo DMG-IUEG apresentou menores níveis de relaxina (p=,001). Além disso, a estratificação do grupo de acordo com a força do assoalho pélvico demonstrou que participantes com DMG e força 0-2 (MOS) tiveram menores níveis de relaxina que o grupo não-DMG (p=,023) e que participantes com DMG e força 3-5 (MOS) (p=,029). As concentrações de relaxina apresentaram-se ainda mais diminuídas no grupo DMG-IUEG quanto comparado a todos os outros 3 grupos (p=,001). Conclusão 2) Os níveis de relaxina estão relacionados com a presença de IUEG, no entanto a combinação do DMG e IUEG e força muscular do AP diminuída apresenta menores valores de relaxina quando comparado com outros grupos. Palavras-Chaves: Assoalho pélvico; diabetes mellitus gestacional; músculo do assoalho pélvico; relaxina; eletromiografia.
Introduction: Pregnancy is the event in which the pelvic floor muscles (PFM) receive an important overload. The appearance of functional changes during and/or after pregnancy will depend on the pregnant woman's muscular response to these overloads. The most widespread factors that will influence PFM are maternal weight gain, uterine volume, changes in alignment, pathological changes associated with pregnancy and hormonal factors. The newborn's weight and episiotomy are added to the risk factors for the development or worsening of postpartum dysfunctions. Gestational Diabetes Mellitus (GDM) is a pathological alteration specific to pregnancy that is screened for the first time during the pregnancy period. It is recommended by the American Diabetes Association (ADA) that between the 24th and the 28th gestational week the blood glucose test and oral tolerance test be performed. In the context of muscle changes, the action of gestational hyperglycemia (GH) was documented by experimental studies that demonstrated the same behavior in severe and moderate GDM, depicting morphological changes in the urethral muscle fibers, characterized by thinning, disorganization, in addition to muscle atrophy. Other structures are also affected by hyperglycemia, clinical and experimental studies have shown changes in the composition of the extracellular matrix, fibrosis, changes in the ultrastructure such as accumulation of mitochondria, increase in drops of lipids and accumulation of glycogen granules in the moderate pregnant diabetic group. All of these changes can negatively influence the functioning of PFM and cause pelvic floor muscle dysfunctions (PFMD), such as urinary incontinence (UI). Added to this information are the hormonal changes in pregnancy that can contribute to a decrease in muscle function. The hormone relaxin is part of the insulin superfamily and is related to the maintenance of pregnancy and the main pregnancy adaptations, mainly on the cardiovascular system and connective tissue. In connective tissue, relaxin-2 alters the density and amount of collagen in the extracellular matrix, in addition to increasing soluble collagen and decreasing insoluble ones, this alteration remodels the tissue more firmly into more elastic. There is also the action of collagen-degrading enzymes that give anti-fibrotic characteristics to this hormone, a process that prepares the pelvis for the delivery process that results in laxity of the ligaments, fascias and pubic symphysis, with consequent interference in the pelvic support system. In addition, relaxin increases the activity of metalloproteinases in the urinary tract, which can decrease the ability of PFM to recover after delivery. This is probably due to the fact that PFM depend on these components for the ideal support to occur and ensure that their function is performed effectively. This dependence relationship between the integrity of the connective tissue and the effective muscle action is evidenced through a study that demonstrated high levels of relaxin are significantly related to the presence of PFMD during pregnancy. The literature shows that pregnant women diagnosed with clinical diabetes and GDM had increased levels of relaxin in relation to non-diabetic pregnant women regardless of the trimester. A fact that can be explained by relaxin increasing the binding of insulin-to-insulin receptors in adipocytes, however the mechanism of this increase in its concentration has not yet been clarified and seems to be related to adjustments in the pregnancy itself complicates by diabetes. Despite the themes of hyperglycemic pregnancy, UI, relaxin being treated in the literature, studies present the results separately and there are no studies that interrelate the three factors, to understand their dynamics together. The present thesis is structured in 2 articles that will bring more knowledge about the theme. Therefore, serum dosages of the hormone relaxin will be performed on the participants. Pregnancy-specific urinary incontinence (PS – UI) and postpartum UI will be assessed by validated instruments that measure the severity and impact of UI. PFM function will be assessed by electromyography, an exam that is recommended by the International Continence Society and International Urogynecological Association, to record the bioelectric extracellular activity generated by muscle fibers and, thus, to infer about neuromuscular behavior. Justification: The Diamater Study Group of the Faculty of Medicine of Botucatu has endeavored to study in recent years the effect of GDM on pelvic floor (PF). Barbosa et al. (2011) in their study confirmed an association between GDM and the presence of low pressure of contraction of the PFM, two years after cesarean section. Translational clinical and experimental studies have identified changes in the characteristics of muscle fibers and extracellular matrix. These results corroborate the clinical results that specific urinary incontinence of pregnancy with GDM is associated with PFMD. The themes relaxin, GH and PFM function are addressed individually, but it is observed that they have points that converge and that need to be investigated in association. No studies were found in the literature that address the impact of this increase in the levels of the hormone relaxin on the electromyographic parameters in the PFM in pregnant women with GDM and GH, indicating that an important gap needs to be answered to identify factors that interfere performance of PFM. The results may assist in the management and detection of possible risk factors for dysfunctions and in this way plan and propose conducts of a minimizing, curative or preventive character. Article 1 Objectives: 1) To analyze the progression of the neuromuscular pattern of the PF in women with a history of GDM during two gestational moments and 18-24 months after delivery. Methods: 1) The aim of was to compare PFM activation pattern between GDM and non-GDM women from 24-30 gestational weeks to 18-24 months postpartum during a standard clinical test during gestation and postpartum. The main inclusion criteria to the study were: pregnant women between 24-30 weeks of gestation; singleton pregnancy. The threshold to compose the 2 groups of study was the guidelines proposed by American Diabetes Association using the 75g oral glycemic tolerance test (75g-OGTT), participants who had fasting ≥92 mg/dL or 1 hour ≥180 mg/dL or 2 hours ≥153 mg/dL were allocated to the GDM group. The participants who had lower values allocated the non-GDM group. The recruitment takes place on Perinatal Diabetes Research Center (PDRC) of Botucatu Medical School/UNESP/Brazil, between 2015 and 2018. The participants who accepted to participate were evaluate at 24-30 weeks of gestation by questionnaire with personal details, clinical and obstetric historic and body mass index (BMI) was measured. In sequence, they were explained about the PFM examination, positioned in a starcher in supine position and a digital palpation were performed to confirm that participants were able to understand the command. After, the electromyography exam preparation was performed using a vaginal probe sensor with two opposite stainless-steel electrodes (85 x 25 mm) positioned on both vaginal sidewalls. The glazer protocol was used to standardize the contractions: 60-seconds rest (pre-baseline), 1-sec phasic (flick) contraction repeated 5 times (5x), with 10-sec rest in between, 5 x 10-sec tonic contractions, with 10-sec rest in between, 60-sec endurance contraction and 1x 60-sec rest (post-Baseline). After the end of the first time-point the participant were scheduled to 36-38 weeks of gestation and 18-24 months postpartum and the same procedures were performed in each step. Data analyses focus on the amplitude measurements RMS related to average, peak and standard deviation variability was done. Analysis about the time between onset to peak and peak to offset was performed. In addition, rate of neural drive during the beginning and end of the contraction and before and after peak. The full RMS EMG waveforms from the Flick and Hold tasks were compared between groups using the technique of wavelet-functional ANOVA. Results: 1) Demographic and obstetric data showed homogeneity between groups. GDM group showed during 1-sec Flick contractions lower EMG amplitudes on post-partum. Additionally, although GDM group achieve peak PFM EMG amplitudes similarly to the non-GDM, they took longer to return to baseline levels. During 10-sec Hold contractions, the GDM group sustained lower levels of PFM activation than the non-GDM group at both 36-38 weeks of gestation and 18-24 months postpartum when compared to the non-GDM group. Conclusion: 1) The results suggest that GDM impaired PFM control mainly on 1 sec-flicks and 10-sec hold contraction, which appears to develop late-pregnancy and extends long-term postpartum. This motor behaviour may play a role on pelvic floor dysfunctions and should be focus of following mechanistic and clinical research. Article 2 Objective: 2) To investigate relaxin-2 concentration between DMG and non-DGM pregnant according to UI and pelvic function status. Methods: 2) This is a cross-sectional study which evaluate 282 pregnant from 24 weeks of gestation. The participants were divided into two groups, non-GDM and GDM, according to American diabetes Association’s diabetes mellitus gestational threshold. In addition, according to sub analysis the both groups were subdivided according to the presence of pregnancy specific urinary incontinence (PSUI): non-GDM-C (non-GDM continent), non-GDM-PSUI (non-GDM incontinent), GDM-C (DMG continent), GDM-PSUI (GDM incontinent). All participants carried out questionnaires about clinical, obstetric and urinary continence status ("International Consultation on Incontinence Questionnaire - Short Form"- ICIQ-SF and the “Incontinence Severity Index” -ISI). Followed by pelvic floor muscle evaluation by the PERFECT scheme which strength, endurance and fast contraction were evaluated. Results 2) Serum relaxin-2 concentrations were significantly lower in pregnant with PSUI both in non-GDM and GDM pregnancies, but GDM showed the lowest concentration. In addition, the stratification of the groups according to PFM strength showed that pregnancy with GDM and MOS 0-2 had significantly lower levels than non-GDM and GDM with MOS 3-5. Relaxin-2 level was intensely lower in GDM-PSUI pregnant with MOS 0-2 when compared with the other 3 groups. Conclusion: 2) The relaxin-2 concentration was related to the presence of PSUI, but the combination between GDM and PSUI and lower levels of pelvic floor strength leads to lower levels of relaxin-2 when compared to the other 3 groups.
Introduction: Pregnancy is the event in which the pelvic floor muscles (PFM) receive an important overload. The appearance of functional changes during and/or after pregnancy will depend on the pregnant woman's muscular response to these overloads. The most widespread factors that will influence PFM are maternal weight gain, uterine volume, changes in alignment, pathological changes associated with pregnancy and hormonal factors. The newborn's weight and episiotomy are added to the risk factors for the development or worsening of postpartum dysfunctions. Gestational Diabetes Mellitus (GDM) is a pathological alteration specific to pregnancy that is screened for the first time during the pregnancy period. It is recommended by the American Diabetes Association (ADA) that between the 24th and the 28th gestational week the blood glucose test and oral tolerance test be performed. In the context of muscle changes, the action of gestational hyperglycemia (GH) was documented by experimental studies that demonstrated the same behavior in severe and moderate GDM, depicting morphological changes in the urethral muscle fibers, characterized by thinning, disorganization, in addition to muscle atrophy. Other structures are also affected by hyperglycemia, clinical and experimental studies have shown changes in the composition of the extracellular matrix, fibrosis, changes in the ultrastructure such as accumulation of mitochondria, increase in drops of lipids and accumulation of glycogen granules in the moderate pregnant diabetic group. All of these changes can negatively influence the functioning of PFM and cause pelvic floor muscle dysfunctions (PFMD), such as urinary incontinence (UI). Added to this information are the hormonal changes in pregnancy that can contribute to a decrease in muscle function. The hormone relaxin is part of the insulin superfamily and is related to the maintenance of pregnancy and the main pregnancy adaptations, mainly on the cardiovascular system and connective tissue. In connective tissue, relaxin-2 alters the density and amount of collagen in the extracellular matrix, in addition to increasing soluble collagen and decreasing insoluble ones, this alteration remodels the tissue more firmly into more elastic. There is also the action of collagen-degrading enzymes that give anti-fibrotic characteristics to this hormone, a process that prepares the pelvis for the delivery process that results in laxity of the ligaments, fascias and pubic symphysis, with consequent interference in the pelvic support system. In addition, relaxin increases the activity of metalloproteinases in the urinary tract, which can decrease the ability of PFM to recover after delivery. This is probably due to the fact that PFM depend on these components for the ideal support to occur and ensure that their function is performed effectively. This dependence relationship between the integrity of the connective tissue and the effective muscle action is evidenced through a study that demonstrated high levels of relaxin are significantly related to the presence of PFMD during pregnancy. The literature shows that pregnant women diagnosed with clinical diabetes and GDM had increased levels of relaxin in relation to non-diabetic pregnant women regardless of the trimester. A fact that can be explained by relaxin increasing the binding of insulin-to-insulin receptors in adipocytes, however the mechanism of this increase in its concentration has not yet been clarified and seems to be related to adjustments in the pregnancy itself complicates by diabetes. Despite the themes of hyperglycemic pregnancy, UI, relaxin being treated in the literature, studies present the results separately and there are no studies that interrelate the three factors, to understand their dynamics together. The present thesis is structured in 2 articles that will bring more knowledge about the theme. Therefore, serum dosages of the hormone relaxin will be performed on the participants. Pregnancy-specific urinary incontinence (PS – UI) and postpartum UI will be assessed by validated instruments that measure the severity and impact of UI. PFM function will be assessed by electromyography, an exam that is recommended by the International Continence Society and International Urogynecological Association, to record the bioelectric extracellular activity generated by muscle fibers and, thus, to infer about neuromuscular behavior. Justification: The Diamater Study Group of the Faculty of Medicine of Botucatu has endeavored to study in recent years the effect of GDM on pelvic floor (PF). Barbosa et al. (2011) in their study confirmed an association between GDM and the presence of low pressure of contraction of the PFM, two years after cesarean section. Translational clinical and experimental studies have identified changes in the characteristics of muscle fibers and extracellular matrix. These results corroborate the clinical results that specific urinary incontinence of pregnancy with GDM is associated with PFMD. The themes relaxin, GH and PFM function are addressed individually, but it is observed that they have points that converge and that need to be investigated in association. No studies were found in the literature that address the impact of this increase in the levels of the hormone relaxin on the electromyographic parameters in the PFM in pregnant women with GDM and GH, indicating that an important gap needs to be answered to identify factors that interfere performance of PFM. The results may assist in the management and detection of possible risk factors for dysfunctions and in this way plan and propose conducts of a minimizing, curative or preventive character. Article 1 Objectives: 1) To analyze the progression of the neuromuscular pattern of the PF in women with a history of GDM during two gestational moments and 18-24 months after delivery. Methods: 1) The aim of was to compare PFM activation pattern between GDM and non-GDM women from 24-30 gestational weeks to 18-24 months postpartum during a standard clinical test during gestation and postpartum. The main inclusion criteria to the study were: pregnant women between 24-30 weeks of gestation; singleton pregnancy. The threshold to compose the 2 groups of study was the guidelines proposed by American Diabetes Association using the 75g oral glycemic tolerance test (75g-OGTT), participants who had fasting ≥92 mg/dL or 1 hour ≥180 mg/dL or 2 hours ≥153 mg/dL were allocated to the GDM group. The participants who had lower values allocated the non-GDM group. The recruitment takes place on Perinatal Diabetes Research Center (PDRC) of Botucatu Medical School/UNESP/Brazil, between 2015 and 2018. The participants who accepted to participate were evaluate at 24-30 weeks of gestation by questionnaire with personal details, clinical and obstetric historic and body mass index (BMI) was measured. In sequence, they were explained about the PFM examination, positioned in a starcher in supine position and a digital palpation were performed to confirm that participants were able to understand the command. After, the electromyography exam preparation was performed using a vaginal probe sensor with two opposite stainless-steel electrodes (85 x 25 mm) positioned on both vaginal sidewalls. The glazer protocol was used to standardize the contractions: 60-seconds rest (pre-baseline), 1-sec phasic (flick) contraction repeated 5 times (5x), with 10-sec rest in between, 5 x 10-sec tonic contractions, with 10-sec rest in between, 60-sec endurance contraction and 1x 60-sec rest (post-Baseline). After the end of the first time-point the participant were scheduled to 36-38 weeks of gestation and 18-24 months postpartum and the same procedures were performed in each step. Data analyses focus on the amplitude measurements RMS related to average, peak and standard deviation variability was done. Analysis about the time between onset to peak and peak to offset was performed. In addition, rate of neural drive during the beginning and end of the contraction and before and after peak. The full RMS EMG waveforms from the Flick and Hold tasks were compared between groups using the technique of wavelet-functional ANOVA. Results: 1) Demographic and obstetric data showed homogeneity between groups. GDM group showed during 1-sec Flick contractions lower EMG amplitudes on post-partum. Additionally, although GDM group achieve peak PFM EMG amplitudes similarly to the non-GDM, they took longer to return to baseline levels. During 10-sec Hold contractions, the GDM group sustained lower levels of PFM activation than the non-GDM group at both 36-38 weeks of gestation and 18-24 months postpartum when compared to the non-GDM group. Conclusion: 1) The results suggest that GDM impaired PFM control mainly on 1 sec-flicks and 10-sec hold contraction, which appears to develop late-pregnancy and extends long-term postpartum. This motor behaviour may play a role on pelvic floor dysfunctions and should be focus of following mechanistic and clinical research. Article 2 Objective: 2) To investigate relaxin-2 concentration between DMG and non-DGM pregnant according to UI and pelvic function status. Methods: 2) This is a cross-sectional study which evaluate 282 pregnant from 24 weeks of gestation. The participants were divided into two groups, non-GDM and GDM, according to American diabetes Association’s diabetes mellitus gestational threshold. In addition, according to sub analysis the both groups were subdivided according to the presence of pregnancy specific urinary incontinence (PSUI): non-GDM-C (non-GDM continent), non-GDM-PSUI (non-GDM incontinent), GDM-C (DMG continent), GDM-PSUI (GDM incontinent). All participants carried out questionnaires about clinical, obstetric and urinary continence status ("International Consultation on Incontinence Questionnaire - Short Form"- ICIQ-SF and the “Incontinence Severity Index” -ISI). Followed by pelvic floor muscle evaluation by the PERFECT scheme which strength, endurance and fast contraction were evaluated. Results 2) Serum relaxin-2 concentrations were significantly lower in pregnant with PSUI both in non-GDM and GDM pregnancies, but GDM showed the lowest concentration. In addition, the stratification of the groups according to PFM strength showed that pregnancy with GDM and MOS 0-2 had significantly lower levels than non-GDM and GDM with MOS 3-5. Relaxin-2 level was intensely lower in GDM-PSUI pregnant with MOS 0-2 when compared with the other 3 groups. Conclusion: 2) The relaxin-2 concentration was related to the presence of PSUI, but the combination between GDM and PSUI and lower levels of pelvic floor strength leads to lower levels of relaxin-2 when compared to the other 3 groups.
Descrição
Palavras-chave
Assoalho pélvico, Diabetes mellitus gestacional, Relaxina, Eletromiografia, Pelvic floor, Gestational diabetes, Relaxin, Electromyography