Exercício físico e metformina na prevenção a pré-eclâmpsia: revisão sistemática

Nascimento, Iramar Baptistella do; Nunes, Mayco Morais; Fleig, Raquel

Resumo

Introdução:

A pré-eclâmpsia é uma desordem que pode ocorrer durante a gravidez, sendo ainda de etiologia desconhecida e/ou de causas multifatoriais.

Objetivo:

Verificar se o exercício físico terapêutico e a metformina podem ser coadjuvantes na prevenção da pré-eclâmpsia.

Método:

Trata-se de uma revisão sistemática da literatura nas bases de dados PubMed/MEDLINE, Web of Science, Scopus, LILACS e Cochrane. Esta revisão seguiu os critérios do cheklist PRISMA. Na avaliação de viés utilizou-se o Cochrane Handbook for Systematical Reviews of Interventions (Version 5.1.0) para os ensaios clínicos e a escala de Downs e Black para os estudos de coorte e caso-controle.

Resultados:

17 estudos estavam dentro dos critérios estabelecidos. Os temas avaliados foram: pré-eclâmpsia, fatores metabólicos cardiovasculares, terapêuticas fisioterápicas e os efeitos do exercício físico e da metformina no sistema circulatório.

Conclusão:

Existe a necessidade de técnicas adaptadas e novos protocolos de acordo com as contingências e intercorrências da gestação. Durante a gravidez, sugere-se uma maior interdisciplinaridade de conhecimento entre os profissionais e que a terapêutica receba ajustes de encontro às alterações metabólicas do sistema reprodutor. O estudo sugere para prevenção a pré-eclâmpsia um programa de exercícios individuais que contemplem uma maior assistência, verificação e/ou compreensão sobre as possíveis alterações e seus limites durante a gestação. Bem como, o coadjuvante uso da metformina de 1000 mg/d na fase inicial, com o propósito de se manter os efeitos do fármaco em razão da depuração renal durante a gestação, até atingir no máximo 1500 mg/d, para evitar as decorrências colaterais da droga.

Palavras-chave:
Modalidades de Fisioterapia; Gravidez; Metformina; Hipertensão Induzida pela Gravidez

[1] *IBN: PhD, e-mail: iramar.nascimento@udesc.br MMN: PhD, e-mail: mayco.nunes@udesc.br RF: MS, e-mail: raquel.fleig@udesc.br

Author and year of publication	Type of study	Population and sample	Dosage and / or method	Segment	Country	Risk of bias level
Tertti et al. [¹¹11 Tertti K, Ekblad U, Koskinen P, Vahlberg T, Ronnemaa T. Metformin vs. insulin in gestational diabetes. A randomized study characterizing metformin patients needing additional insulin. Diabetes Obes Metab. 2013;15(3):246-51.] (2013)	RCT	217 pregnant women, aged ≥ 18 years Metformin (n = 110) Insulin (n = 107)	500 mg/d to 1,000 mg/d	6 to 7 months	Finland	Low
Rowan et al. [¹²12 Rowan JA, Hague WM, Gao W, Battin MR, Moore MP. Metformin versus insulin for the treatment of gestational diabetes. N Engl J Med. 2008;358(19):2003-15.] (2008)	RCT	751 pregnant women, aged between 18 and 45 years Metformin (n = 363) Insulin (n = 370)	2,500 mg/d	4 to 5 months	New Zealand and Australia	Low
Syngelaki et al. [³⁵35 Syngelaki A, Nicolaides KH, Balani J, Hyer S, Akolekar R, Kotecha R, et al. Metformin versus Placebo in Obese Pregnant Women without Diabetes Mellitus. N Engl J Med. 2016;374(5):434-43.] (2016)	RCT	450 pregnant women, aged ≥ 18 years Metformin (n = 202) Placebo (n = 198)	500 mg/d to 3,000 mg/d	5 to 6 months	USA and United Kingdom	Low
Chiswick et al. [⁴⁰40 Chiswick C, Reynolds RM, Denison F, Drake AJ, Forbes S, Newby DE, et al. Effect of metformin on maternal and fetal outcomesin obese pregnant women (EMPOWaR): a randomised, double-blind, placebo-controlled trial. Lancet Diabetes Endocrinol. 2015;3(10):778-86.] (2015)	RCT	449 pregnant women, aged ≥ 16 years Metformin (n = 226) Placebo (n = 223)	500 mg/d to 2,500 mg/d	5 to 6 months	United Kingdom	Low
Vanky et al. [⁴¹41 Vanky E, Salvesen KÅ, Heimstad R, Fougner KJ, Romundstad P, Carlsen SM. Metformin reduces pregnancy complications without affecting androgen levels in pregnant polycystic ovary syndrome women: results of a randomized study. Hum Reprod. 2004;19(8):1734-40.] (2004)	RCT	40 pregnant women, aged between 18 and 40 years Metformin (n = 18) Placebo (n = 22)	1,700 mg/d	4 to 5 months	Norway	Moderate
Vanky et al. [⁴²42 Vanky E, Stridsklev S, Heimstad R, Romundstad P, Skogøy K, Kleggetveit O, et al. Metformin versusplacebo from first trimester to delivery in polycystic ovarysyndrome: a randomized, controlled multicenter study. J Clin Endocrinol Metab. 2010;95(12):448-55.] (2010)	RCT	273 pregnant women, aged between 18 and 42 years Metformin (n = 135) Placebo (n = 138)	2,000 mg/d	5 to 6 months	Norway	Low
Hameed et al. [⁴³43 Hameed A, Shreif H, Mowafy H. The role of continuing metformin therapy during pregnancy in the reduction of gestational diabetes and improving pregnancy outcomes in women with polycystic ovary syndrome. Middle East Fertil Soc J. 2011;16(3):204-8.] (2011)	RCT	57 pregnant women, aged ≥ 18 years Metformin (n = 31) Control group (n = 26)	2,500 mg/d	2 to 3 months	Egypt	Moderate
Niromanesh et al. [⁴⁴44 Niromanesh S, Alavi A, Sharbaf FR, Amjadi N, Moosavi S, Akbari S. Metformin compared with insulin in the management of gestational diabetes mellitus: a randomized clinical trial. Diabetes Res Clin Pract. 2012;98(3):422-9.] (2012)	RCT	Pregnant women, aged ≥ 18 years Metformin (n = 80) Control group (n = 80)	500 mg/d to 2,500 mg/d	4 to 5 months	Iran	Moderate

Author and year of publication	Type of study	Population and sample	Dosage and / or method	Segment	Country	Risk of bias level
Barakat et al. [²²22 Barakat R, Pelaez M, Montejo R, Luaces M, Zakynthinaki M. Exercise during pregnancy improves maternal health perception: A randomized controlled trial. Am J Obstet Gynecol. 2011;204(5):402.e1-7.] (2011)	RCT	80 pregnant women aged between 23-32 years Intervention group (n = 40) Control group (n = 40)	Exercise program in sedentary pregnant women	7 months	Spain	Low
Kasawara et al. [⁴⁸48 Kasawara KT, Burgos CS, Nascimento SL, Ferreira NO, Surita FG, Pinto e Silva JL. Maternal and perinatal outcomes of exercise in pregnant women with chronic hypertension and/or previous preeclampsia: a randomized controlled trial. ISRN Obstet Gynecol. 2013;2013:857047.] (2013)	RCT	116 pregnant women ≥ 18 years old Intervention group (n = 58) Control group (n = 58)	Physical exercise once a week	4 to 5 months	Brazil	Moderate
Pivarnik et al.[⁴⁹49 Pivarnik JM, Ayres NA, Mauer MB. Effects of maternal aerobic fi tness on cardiorespiratory responses to exercise. Med Sci Sports Exerc. 2003;25(9):993-8.] (2003)	CT	16 pregnant women Intervention group (n = 10) Control group (n = 6)	Programs (15 min) performed at a certain heart rate (HR: 140 b.min^-1).	3 months during pregnancy 12 weeks after delivery	USA	Moderate
Hartman et al. [⁵⁸58 Hartman S, Kolble N, Rake A, Bung P, Huch A, Ruch R. Aqua fit during pregnancy: maternal and fetal hemodynamic responses during rest, immersion and exercise. Geburtshilfe und Frauenheilkunde. 2001;61(12):977-82.] (2001)	CT	32 pregnant women aged ≥ 18 years	Adequacy of aerobic exercise in liquid environment	3 to 4 months	Switzerland	Moderate
Domingues et al. [⁶¹61 Domingues MR, Bassani, DG, Silva SG, Coll CVN, Silva BGC, Hallal PC. Physical activity during pregnancy and maternal-child health (PAMELA): study protocol for a randomized controlled. Trials. 2015;16:227.] (2015)	RCT	639 pregnant women Intervention group (n = 213) Control group (n = 426)	Proposal for different exercise programs	3 months and postpartum	Brazil	Low

Study and year of publication	Type of study	Population and sample	Therapeutic exercise and / or method	Segment	Country	Escore Downs Black /RF (%)
Prevedel et al. [⁴⁶46 Prevedel TTS, Calderon IMP, De Conti MH, Consonni EB, Rudge MVC. Repercussões maternas e perinatais da hidroterapia na gravidez. Rev Bras Ginecol Obstet. 2003;25(12):53-9.] (2003)	Prospective cohort	60 pregnant women Study group (n = 22) Control group (n = 19)	Hydrotherapy program	4 to 5 months	Spain	11/22 RF: 72.72
Sorensen et al. [⁵⁰50 Sorensen TK, Williams MA, Lee IM, Dashow EE, Thompson ML, Luthy DA. Recreational physical activity during pregnancy and risk of preeclampsia. Hypertension. 2003;41(6):1273-80.] (2003)	Case control	386 pregnant women	Qualitative and quantitative data on your usual walking pace	First 5 months	Brazil	17/22 RF: 77.27
Magnus et al. [⁵⁹59 Magnus P, Trogstad L, Owe KM, Olsen SF, Nystad W. Recreational Physical Activity and the Risk of Preeclampsia: A Prospective Cohort of Norwegian Women. Am J Epidemiol. 2008;168(8):952-7.] (2008)	Prospective cohort	Data set of 59,573 pregnant women	Estimation of PE according to physical activity	Collection between 14-22 weeks of gestation	Norway	18/22 RF: 81.81
Scholten et al. [⁶⁰60 Scholten RR, Thijssen DJ, Lotgering FK, Hopman MT, Spaanderman ME. Cardiovascular effects of aerobic exercise training in formerly preeclamptic women and healthy parous control subjects. Am J Obstet Gynecol. 2014;211(5):516.e1-11.] (2014)	Prospective study	44 pregnant women Study group (n = 24) Control group (n = 20)	Estimation of autonomic control from PE. Physical activity program	Submitted to the exercise program 6-12 months postpartum	Netherlands	14/22 RF: 63.63

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