Alterações do sono e do ritmo circadiano em pacientes com diabetes gestacional

Abstract

Gestational Diabetes Mellitus (GDM) and sleep disorders are frequent in pregnancy and both are associated with adverse pregnancy outcomes, including miscarriage, prematurity, macrosomia and pre-eclampsia. Researchers demonstrates a connection between sleep disorders, depression, insulin resistance and high blood pressure, and studies evaluating sleep behavior in GDM are needed. Objectives: Evaluate sleep quality, sleep-wake rhythm, chronotype, depressive symptoms and fatigue in GDM. Methodology: This is a prospective cohort study, evaluating GDM in the second and third trimester, age ≥ 20 years, attending a reference unit of public health care system. A group of pregnant women, matched for age and gestational age (Control), without comorbidities and identified as uncomplicated pregnancies (UP) were also evaluated. The Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Facco OSA Risk, Horne-Östberg Morningness Eveningness-Questionnaire (MEQ), Edinburgh Postnatal Depression Scale (EPDS), Fatigue Severity Scale (FSS) questionnaires were used. An actigraphic record and the 6- sulfatoxymelatonin (MT6s) in nocturnal urine were determined. Behavioral, clinical and pregnancy outcomes associations were studied. Patients with GDM and pregnant women with UP were compared. Data on maternal-fetal outcomes were collected during the first postpartum visit. The study was approved by the Ethics and Research Committee of the UFC (2.521.562). Results: A total of 448 pregnant women were evaluated: 311 with GDM and 93 with UP. Poor sleep quality (PSQI ≥ 6) was more frequent in GDM (64.5%) than in HR (45.7%, p < 0.001). Total sleep time was shorter in DMG (6.68h) than in HR (7h; < 0.001. The urinary MT6s was inversely related to fatigue (p = 0.03) and OSA risk (p = 0.03), but were similar among GDM and UP women. In GDM, hypertension was associated with a higher risk of sleep apnea (p < 0.001) and insomnia severity (p = 0.04). Previous history of insomnia and depression was associated with sleep disorders during pregnancy. In actigraphy, the time awake after sleep onset (WASO) was associated with a higher HbA1c (p = 0.02), fasting glucose in OGTT (p =0.04) and Fatigue score (p = 0.02). In GDM, fatigue (p = 0.03) and depressive symptoms (p =0.04) were associated with lower sleep efficiency. Low daytime activity rates were associated with higher fasting blood glucose (p=0.01) and higher risk of IGT after GDM. Among GDM patients, 49.5%, had morning preference, 43.6% indifferent and 6.9% evening preference. The evening chronotype was associated with pre-eclampsia (p = 0.02) and NICU admission (p = 0.03). Eveningness was associated with poor sleep quality (p = 0.01), greater severity of insomnia (p <0.001), depressive symptoms (p < 0.01) and fatigue (p < 0.001). Also, a linear analysis showed that lower MEQ had more pre-eclampsia [p = 0.002; OR = 0.94; CI 0.90-0.97] maintained after controlling for HBP, sleep quality, fatigue and depressive symptoms [p = 0.02; OR=4.13; CI: 1.23-8.22]. Poor sleep quality was associated with NICU admission; fatigue with large-for-gestational-age newborns (p = 0.01); and the high risk for OSA with worst blood glucose, higher need of pharmacological treatment and gestational hypertension (P < 0.001). Conclusions: Sleep disturbances are frequent in pregnancy, and worst in GDM, where it can interfere with metabolic measures and be associated with serious adverse pregnancy outcomes. The assessment of sleep parameters and circadian rhythm in the routine of prenatal care might be important to a health pregnancy