Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study

Time and mode of delivery in diabetic pregnancy: a review

The review presents some renewed data on the problem of optimal time and modes of delivery for women with various types of diabetes mellitus (DM 1 and 2, gestational diabetes). The necessity of making the universal delivery strategy algorithm for women with DM comes out of adverse outcomes high frequency, where the main cases are fetal macrosomia, fetal shoulder dystocia and perinatal mortality. Despite significant interest for this issue, there is still no common delivery tactics in the world for pregnant women with carbohydrate metabolism disorders. The main obstacle is evidence-based tests and meta-analysis insufficiency. So far, further studies are necessary to obtain high quality data concerning optimal terms and modes of delivery for women with DM.

Preeclampsia in women with pregestational diabetes - a cohort study

Aims: To evaluate risk factors for preeclampsia (PE) in women with pregestational diabetes.Methods: Retrospective cohort study of women with pregestational diabetes cared for at a specialized prenatal care facility. Maternal characteristics at booking and during pregnancy were studied for their association with preeclampsia. Multivariable models were tested using Poisson regression with robust estimates; results were expressed as relative risk (RR) and 95% confidence interval (CI).Results: Preeclampsia was diagnosed in 62 of 206 women (30%, 95% CI 24-37%). Previous chronic hypertension was found in 53 subjects (26%; 95% CI 20-32%), of whom 41 (77%, 95% CI 64-88) were type 2 women. Type 1 diabetes, chronic hypertension, systolic blood pressure >124 mmHg at booking and gestational weight gain, either total or excessive for body mass index category, behaved as independent risk factors.Conclusions: In women with pregestational diabetes, some risk factors may predict PE, similar to those found in non-diabetic pregnant women. Two non-modifiable factors (type of diabetes and chronic hypertension) and two modifiable ones (systolic blood pressure levels and gestational weight gain) were found relevant in this cohort. A policy of close monitoring of blood pressure and weight gain, aiming adequate weight gain, may be added to current recommended measures. The high prevalence of PE in women with prepregnancy diabetes, especially those with initial pregnancy systolic blood pressure >124 mmHg, supports a policy of early institution of low dose aspirin. Further multicentric studies will help define the role of these risk factors as contributors to PE in pregestational diabetes.

Modelling potential cost savings from use of real-time continuous glucose monitoring in pregnant women with Type 1 diabetes

AIM

To investigate potential cost savings associated with the use of real-time continuous glucose monitoring (RT-CGM) throughout pregnancy in women with Type 1 diabetes.

METHODS

A budget impact model was developed to estimate, from the perspective of National Health Service England, the total costs of managing pregnancy and delivery in women with Type 1 diabetes using self-monitoring of blood glucose (SMBG) with and without RT-CGM. It was assumed that the entire modelled cohort (n = 1441) would use RT-CGM from 10 to 38 weeks' gestation (7 months). Data on pregnancy and neonatal complication rates and related costs were derived from published literature, national tariffs, and device manufacturers.

RESULTS

The cost of glucose monitoring was £588 with SMBG alone and £1820 with RT-CGM. The total annual costs of managing pregnancy and delivery in women with Type 1 diabetes were £23 725 648 with SMBG alone, and £14 165 187 with SMBG and RT-CGM; indicating potential cost savings of approximately £9 560 461 from using RT-CGM. The principal drivers of cost savings were the daily cost of neonatal intensive care unit (NICU) admissions (£3743) and the shorter duration of NICU stay (mean 6.6 vs. 9.1 days respectively). Sensitivity analyses showed that RT-CGM remained cost saving, albeit to lesser extents, across a range of NICU costs and durations of hospital stay, and with varying numbers of daily SMBG measurements.

CONCLUSIONS

Routine use of RT-CGM by pregnant women with Type 1 diabetes, would result in substantial cost savings, mainly through reductions in NICU admissions and shorter duration of NICU care.

Effect of motivational interviewing on gestational weight gain and fetal growth in pregnant women with type 2 diabetes

Objective

To study how lifestyle coaching with motivational interviewing to improve adherence to healthy eating affects gestational weight gain and fetal growth in pregnant women with type 2 diabetes in a real-world setting.

Research design and methods

A cohort study including a prospective intervention cohort of consecutive, singleton pregnant, Danish-speaking women with type 2 diabetes included between August 2015 and February 2018 and a historical reference cohort included between February 2013 and August 2015. The intervention consisted of a motivational interviewing to improve adherence to healthy eating in addition to routine care. The reference cohort received routine care only. The main outcomes were gestational weight gain and large for gestational age (LGA) infants.

Results

Ninety-seven women were included in the intervention cohort and 92 in the reference cohort. Pre-pregnancy body mass index (32.8±6.9 kg/m2 vs 32.4±7.4 kg/m2, p=0.70), gestational weight gain (9.2±5.8 kg vs 10.2±5.8 kg, p=0.25), HbA1c in early pregnancy (6.7%±1.1% vs 6.5%±1.3% (50±12 mmol/mol vs 48±14 mmol/mol), p=0.32) and late pregnancy (5.9%±0.5% vs 6.0%±0.6% (41±6 mmol/mol vs 42±7 mmol/mol), p=0.34) were comparable in the two cohorts. LGA infants occurred in 20% vs 31%, p=0.07, respectively, and after adjustment for maternal characteristics 14% vs 27% delivered LGA infants (p=0.04). Birth weight z-score was 0.24±1.36 vs 0.61±1.38, p=0.06.

Conclusions

Motivational interviewing to improve adherence to healthy eating in addition to routine care in pregnant women with type 2 diabetes tended to reduce fetal overgrowth without major effect on gestational weight gain. Further studies investigating the cost-benefit of enhancing motivation are needed.

Trial registration number

NCT02883127.

Fetal chronic hypoxia and oxidative stress in diabetic pregnancy. Could fetal erythropoietin improve offspring outcomes?

Oxidative stress is responsible for microvascular complications (hypertension, nephropathy, retinopathy, peripheral neuropathy) of diabetes, which during pregnancy increase both maternal and fetal complications. Chronic hypoxia and hyperglycemia result in increased oxidative stress and decreased antioxidant enzyme activity. However, oxidative stress induces also anti-oxidative reactions both in pregnant diabetes patients and in their fetuses. Not all type 1 diabetes patients with long-lasting disease develop microvascular complications, which suggests that some of these patients have protective mechanisms against these complications. Fetal erythropoietin (EPO) is the main regulator of red cell production in the mother and in the fetus, but it has also protective effects in various maternal and fetal tissues. This dual effect of EPO is based on EPO receptor (EPO-R) isoforms, which differ structurally and functionally from the hematopoietic EPO-R isoform. The tissue protective effects of EPO are based on its anti-apoptotic, anti-oxidative, anti-inflammatory, cell proliferative and angiogenic properties. Recent experimental and clinical studies have shown that EPO has also positive metabolic effects on hyperglycemia and diabetes, although these have not yet been fully delineated. Whether the tissue protective and metabolic effects of EPO could have clinical benefits, are important topics for future research in diabetic pregnancies.

Factors associated with stillbirth in women with diabetes

AIMS/HYPOTHESIS

Stillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors.

METHODS

A retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA_1c data and delivery timing were compared between stillborn and liveborn groups.

RESULTS

Stillbirth rates were 16.1 (95% CI 12.4, 20.8) and 22.9 (95% CI 16.4, 31.8) per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA_1c before pregnancy (OR 1.03 [95% CI 1.01, 1.04]; p = 0.0003) and in later pregnancy (OR 1.06 [95% CI 1.04, 1.08]; p < 0.0001) were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI (OR 1.07 [95% CI 1.01, 1.14]; p = 0.02) and pre-pregnancy HbA_1c (OR 1.02 [95% CI 1.00, 1.04]; p = 0.016) were associated with stillbirth. Risk was highest in infants with birthweights <10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th-90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights >95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week (7.0 [95% CI 3.7, 12.9] per 1000 ongoing pregnancies) among mothers with type 1 diabetes and in the 39th week (9.3 [95% CI 2.4, 29.2]) for type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Maternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies.

Pregnancy outcomes among women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion versus multiple daily injections: A retrospective cohort study

Background

Insulin delivery options for pregnant women with type 1 diabetes mellitus are either continuous subcutaneous insulin infusion or multiple daily injections. The aim of this paper is to compare pregnancy outcomes in women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion or multiple daily injections in pregnancy.

Methods

Retrospective single-centre cohort study of 298 pregnancies booked between 2006 and 2016. Descriptive analysis was performed for HbA1c values. Logistic regression models were created to compare selected maternal and neonatal outcomes.

Results

Continuous subcutaneous insulin infusion was associated with increased risk of large-for-gestational age (aOR 2.00, 95% CI 1.20-3.34) and preterm neonates (aOR 1.80, 95% CI 1.04-3.03). Continuous subcutaneous insulin infusion had no association with increased risk of adverse pregnancy outcomes. No difference in HbA1c values existed between groups.

Conclusion

Using continuous subcutaneous insulin infusion for type 1 diabetes mellitus through pregnancy is associated with increased risk of large-for-gestational age and preterm neonates, without increased risk of associated adverse maternal or neonatal outcomes.

Maternal and neonatal outcomes following a diabetic pregnancy within the context of HIV

OBJECTIVE

To characterize the demographics, comorbidities, management, and outcomes of pregnant women with pre-gestational and gestational diabetes (GDM), including overt and true GDM, taking into account HIV infection and the influence of exposure to oral hypoglycemic agents (OHAs).

METHODS

A review of medical records of 1071 diabetic pregnancies (between 2012 and 2018) at a tertiary hospital in South Africa.

RESULTS

Of the women, 43% had GDM, 19% had type 1 diabetes (T1DM), and 38% had type 2 diabetes (T2DM). Each group had a mean initial body mass index (BMI) >25 kg/m² . Despite poor initial HbA1c for pre-gestational groups, over 90% of the cohort achieved glycemic control by the time of delivery. The rate of prematurity was 30.9%. Perinatal mortality (PNM) was 5.1% for the pre-gestational group and 1.8% for GDM. Of the cohort, 23.9% was HIV infected. PNM was higher in the HIV-infected pregnancies (9.4%) than non-HIV exposed pregnancies (1.8%, P<0.001). The macrosomia rate was higher in the glibenclamide-exposed group than the insulin-alone group (12.2% vs 0%, P=0.025).

CONCLUSION

Obesity is a significant predictor for macrosomia and was high in all groups. In a low-/middle-income country setting with a high prevalence of HIV and high usage of OHAs as an alternative to insulin therapy, HIV might be associated with higher PNM and glibenclamide with increased rates of macrosomia, which warrants further exploration.

Predictors of Large-for-Gestational-Age Birthweight Among Pregnant Women With Type 1 and Type 2 Diabetes: A Retrospective Cohort Study

OBJECTIVE

Our aim in this study was to compare the effects of risk factors for large-for-gestational-age (LGA) birthweight between women with type 1 and type 2 diabetes mellitus (TIDM and T2DM, respectively).

METHODS

A retrospective cohort study was conducted for women with T1DM (n=152) and T2DM (n=255) attending a diabetes/pregnancy clinic during the period from 2009 to 2016. Multiple logistic regression analysis was used to identify variables associated with LGA birthweight.

RESULTS

LGA was significantly higher in those with T1DM (39%) than T2DM (17%) (p<0.001). Among those with T1DM, there was a nonsignificant association between LGA and continuous subcutaneous insulin infusion (odds ratio, 1.17; 95% confidence interval, 0.99 to 1.39; p=0.06) and excess maternal weight gain (T1DM odds ratio, 1.19; 95% confidence interval, 0.99 to 1.43; p=0.069). In those with T2DM, there was an association between LGA and glycated hemoglobin at delivery (T2DM odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; p=0.01).

CONCLUSIONS

In the study population, glycemic control at delivery was predictive of LGA in women with T2DM, and there was a trend toward an association of maternal weight gain and continuous subcutaneous insulin infusion with LGA infants in T1DM. Further study is warranted to better guide targeted interventions to reduce high rates of LGA birthweight in T1DM/T2DM.

Neurocognitive and behavioural outcomes in offspring exposed to maternal pre-existing diabetes: a systematic review and meta-analysis

AIMS/HYPOTHESIS

We performed a systematic review and meta-analysis to determine whether exposure to maternal pre-existing diabetes in pregnancy is associated with neurocognitive or behavioural outcomes in offspring.

METHODS

We searched MEDLINE, EMBASE, PsychINFO, the Cochrane Database of Systematic Reviews and Scopus for studies that examined any neurocognitive or behavioural outcomes in offspring of mothers with pre-existing diabetes in pregnancy in accordance with a published protocol (PROSPERO CRD42018109038). Title and abstract review, full-text review and data extraction were performed independently and in duplicate. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of summary measures were performed using random-effects models.

RESULTS

Nineteen articles including at least 18,681 exposed and 2,856,688 control participants were identified for inclusion. Exposure to maternal pre-existing diabetes in pregnancy was associated with a lower pooled intelligence quotient in the offspring (pooled weighted mean difference -3.07 [95% CI -4.59, -1.55]; I2 = 0%) and an increased risk of autism spectrum disorders (effect estimate 1.98 [95% CI 1.46, 2.68]; I2 = 0%). There was also an increased risk of attention deficit/hyperactivity disorder (pooled HR 1.36 [95% CI 1.19, 1.55]; I2 = 0%), though this was based on only two studies. Although most studies were found to be high quality in terms of participant selection, in many studies, comparability of cohorts and adequacy of follow-up were sources of bias.

CONCLUSIONS/INTERPRETATION

There is evidence to suggest that in utero exposure to maternal pre-existing diabetes is associated with some adverse neurocognitive and behavioural outcomes. It remains unclear what the role of perinatal factors is and the degree to which other environmental factors contribute to these findings.

An overview of the management of diabetes from pre-conception, during pregnancy and in the postnatal period

Diabetes is one of the most common medical conditions complicating pregnancy. Both pre-existing diabetes and gestational diabetes are associated with increased risks to the mother and fetus. These risks can be reduced by improving pre-conception and antenatal care. Pre-conception planning and care is important to ensure women are taking high dose folic acid, to optimise glucose control, to review medications and to screen for and manage any complications. All women with either pre-existing diabetes or gestational diabetes should be reviewed by the antenatal team every 1-2 weeks throughout pregnancy. This is to optimise glucose control and to monitor fetal growth and development. Women with diabetes in pregnancy should receive an individualised care plan for delivery. The exact timing of delivery will depend on maternal glucose control, fetal growth and any other complications. Women diagnosed with gestational diabetes in pregnancy are at high risk of developing both gestational diabetes and type 2 diabetes in the future. After delivery, they should be offered a fasting plasma glucose at 6 weeks or a glycated haemoglobin (HbA1c) at 13 weeks to ensure that the gestational diabetes has resolved and an annual HbA1c.

Psychosocial wellbeing among new mothers with diabetes: Exploratory analysis of the postnatal wellbeing in transition questionnaire

OBJECTIVE

The Postnatal Wellbeing in Transition (PostTrans) Questionnaire assesses psychosocial wellbeing among women transitioning to motherhood while managing pre-existing diabetes. Face and content validity have been previously reported; however the PostTrans questionnaire has 51 items which imposes a substantial burden on respondents. The aim of this study was exploratory analysis of the PostTrans questionnaire to investigate whether a reduction in the number of items was statistically supported, and whether clinically meaningful subscales could be derived.

METHODS

A prospective cohort of women with type 1 or type 2 diabetes was recruited from three metropolitan hospitals in Melbourne, Australia. Women completed surveys across three postnatal time points. Data were pooled for the analysis. Suitability for factor analysis was confirmed and exploratory Principal Components Analysis with oblique rotation was conducted.

RESULTS

The number of responses in the pooled dataset was 117. The reduced PostTrans scale has 27 items and six factors, which together explain 68.7% of the variance. The subscales assess: feeling as if one is coping with diabetes and the infant; feeling anxious and guilty about diabetes; feeling supported by family; sensitivity to the opinions of others; prioritising self-care; and health professional support.

CONCLUSION

The number of items in the PostTrans Questionnaire was reduced from 51 to 27 items. Six meaningful subscales emerged, which can help health professionals identify and address areas in which women with diabetes are experiencing psychosocial difficulties. The revised scale provides a feasible instrument to be tested for psychometric properties in a larger sample.

Continuous glucose monitoring targets in type 1 diabetes pregnancy: every 5% time in range matters

With randomised trial data confirming that continuous glucose monitoring (CGM) is associated with improvements in maternal glucose control and neonatal health outcomes, CGM is increasingly used in antenatal care. Across pregnancy, the ambition is to increase the CGM time in range (TIR), while reducing time above range (TAR), time below range (TBR) and glycaemic variability measures. Pregnant women with type 1 diabetes currently spend, on average, 50% (12 h), 55% (13 h) and 60% (14 h) in the target range of 3.5-7.8 mmol/l (63-140 mg/dl) during the first, second and third trimesters, respectively. Hyperglycaemia, as measured by TAR, reduces from 40% (10 h) to 33% (8 h) during the first to third trimester. A TIR of >70% (16 h, 48 min) and a TAR of <25% (6 h) is achieved only in the final weeks of pregnancy. CGM TBR data are particularly sensor dependent, but regardless of the threshold used for individual patients, spending ≥4% of time (1 h) below 3.5 mmol/l or ≥1% of time (15 min) below 3.0 mmol/l is not recommended. While maternal hyperglycaemia is a well-established risk factor for obstetric and neonatal complications, CGM-based risk factors are emerging. A 5% lower TIR and 5% higher TAR during the second and third trimesters is associated with increased risk of large for gestational age infants, neonatal hypoglycaemia and neonatal intensive care unit admissions. For optimal neonatal outcomes, women and clinicians should aim for a TIR of >70% (16 h, 48 min) and a TAR of <25% (6 h), from as early as possible during pregnancy.

Continuous glucose monitoring in pregnant women with type 1 diabetes: an observational cohort study of 186 pregnancies

AIMS/HYPOTHESIS

The aim of this study was to analyse patterns of continuous glucose monitoring (CGM) data for associations with large for gestational age (LGA) infants and an adverse neonatal composite outcome (NCO) in pregnancies in women with type 1 diabetes.

METHODS

This was an observational cohort study of 186 pregnant women with type 1 diabetes in Sweden. The interstitial glucose readings from 92 real-time (rt) CGM and 94 intermittently viewed (i) CGM devices were used to calculate mean glucose, SD, CV%, time spent in target range (3.5-7.8 mmol/l), mean amplitude of glucose excursions and also high and low blood glucose indices (HBGI and LBGI, respectively). Electronic records provided information on maternal demographics and neonatal outcomes. Associations between CGM indices and neonatal outcomes were analysed by stepwise logistic regression analysis adjusted for confounders.

RESULTS

The number of infants born LGA was similar in rtCGM and iCGM users (52% vs 53%). In the combined group, elevated mean glucose levels in the second and the third trimester were significantly associated with LGA (OR 1.53, 95% CI 1.12, 2.08, and OR 1.57, 95% CI 1.12, 2.19, respectively). Furthermore, a high percentage of time in target in the second and the third trimester was associated with lower risk of LGA (OR 0.96, 95% CI 0.94, 0.99 and OR 0.97, 95% CI 0.95, 1.00, respectively). The same associations were found for mean glucose and for time in target and the risk of NCO in all trimesters. SD was significantly associated with LGA in the second trimester and with NCO in the third trimester. Glucose patterns did not differ between rtCGM and iCGM users except that rtCGM users had lower LBGI and spent less time below target.

CONCLUSIONS/INTERPRETATION

Higher mean glucose levels, higher SD and less time in target range were associated with increased risk of LGA and NCO. Despite the use of CGM throughout pregnancy, the day-to-day glucose control was not optimal and the incidence of LGA remained high.

Improving pregnancy outcomes in women with diabetes mellitus: modern management

Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.

Using the Novel Approach of an Artificial Pancreas to Manage Type 1 Diabetes Mellitus in Pregnancy

Recent National Institute for Health and Care Excellence (NICE) guidelines suggest that insulin pump therapy should be used in pregnant women with Type 1 diabetes mellitus (T1DM) who do not achieve optimal glycaemic control with multiple daily injection (MDI) therapy. Furthermore, a landmark trial has confirmed that prospective continuous glucose monitoring (CGM) may be beneficial for women using both MDI and insulin pumps during pregnancy, with positive effects on neonatal outcomes. More recently, overnight use of an artificial pancreas (AP) with a model-predictive control algorithm has been shown to improve the amount of time women spend within the overnight glucose target range (3.5–7.8 mmol/L) during pregnancy. However, preliminary studies where the AP is used day and night have shown a high degree of interindividual variability in response to the intervention, and further randomised trials are needed to understand which women are suitable candidates for CGM, insulin pump, and AP technology. It is understood that improvements in maternal glycaemic control can minimise the risk of adverse neonatal outcomes. Given the substantial improvements in glycaemic control with AP use outside of pregnancy, the recent advances in AP technology provide hope that AP systems will improve the effectiveness of continuous subcutaneous insulin infusion and CGM during pregnancy. Further research is needed to evaluate whether AP can optimise glucose control and neonatal outcomes in T1DM pregnancy. This paper will discuss emerging technologies available for the management of T1DM in pregnancy.

Real-World Experience of Adding Metformin in Pregnant Women with Type 1 Diabetes in a Chinese Population: A Retrospective Cohort

INTRODUCTION

Glycemic control in pregnant women with type 1 diabetes (T1D) is challenging with only insulin, and the incidence rate of adverse perinatal outcomes is high. Increasing data have indicated the safety and effect of metformin in pregnancy; however, no relevant data are available in pregnant women with T1D. We aimed to investigate glycemic control and perinatal outcomes in pregnant women with T1D in a Chinese population and explored the role of metformin in these patients.

METHODS

We obtained data of 38 pregnant women with T1D who received regular antenatal care and delivered at Peking Union Medical College Hospital (PUMCH) between 1 January 2006 and 31 May 2018. The perinatal outcomes of T1D patients who added metformin as adjunct treatment and those who remained on insulin-alone therapy were compared retrospectively.

RESULTS

Being overweight was common (35.1%) in pregnant women with T1D. On average, the insulin dose increased by 35.30 ± 22.60 unit/day during pregnancy. The cesarean delivery rate was high (65.8%), and fetal macrosomia was the main reason. The change of HbA1c in the metformin-insulin group was more prominent than in the insulin-only group (- 1.47 ± 1.17% vs. - 0.90 ± 1.13%, p = 0.05). There was no statistically significant difference in perinatal outcomes between the two groups.

CONCLUSIONS

The incidence of adverse perinatal outcomes in pregnant women with T1D was high. This study innovatively suggested that metformin could be safe and could contribute to improving glucose management in pregnant women with T1D.

Maternal Glycemic Control in Type 1 Diabetes and the Risk for Preterm Birth: A Population-Based Cohort Study

BACKGROUND

Maternal type 1 diabetes (T1D) has been linked to preterm birth and other adverse pregnancy outcomes. How these risks vary with glycated hemoglobin (or hemoglobin A1c [HbA1c]) levels is unclear.

OBJECTIVE

To examine preterm birth risk according to periconceptional HbA1c levels in women with T1D.

DESIGN

Population-based cohort study.

SETTING

Sweden, 2003 to 2014.

PATIENTS

2474 singletons born to women with T1D and 1 165 216 reference infants born to women without diabetes.

MEASUREMENTS

Risk for preterm birth (<37 gestational weeks). Secondary outcomes were neonatal death, large for gestational age, macrosomia, infant birth injury, hypoglycemia, respiratory distress, 5-minute Apgar score less than 7, and stillbirth.

RESULTS

Preterm birth occurred in 552 (22.3%) of 2474 infants born to mothers with T1D versus 54 287 (4.7%) in 1 165 216 infants born to mothers without diabetes. The incidence of preterm birth was 13.2% in women with a periconceptional HbA1c level below 6.5% (adjusted risk ratio [aRR] vs. women without T1D, 2.83 [95% CI, 2.28 to 3.52]), 20.6% in those with a level from 6.5% to less than 7.8% (aRR, 4.22 [CI, 3.74 to 4.75]), 28.3% in those with a level from 7.8% to less than 9.1% (aRR, 5.56 [CI, 4.84 to 6.38]), and 37.5% in those with a level of 9.1% or higher (aRR, 6.91 [CI, 5.85 to 8.17]). The corresponding aRRs for medically indicated preterm birth (n = 320) were 5.26 (CI, 3.83 to 7.22), 7.42 (CI, 6.21 to 8.86), 11.75 (CI, 9.72 to 14.20), and 17.51 (CI, 14.14 to 21.69), respectively. The corresponding aRRs for spontaneous preterm birth (n = 223) were 1.81 (CI, 1.31 to 2.52), 2.86 (CI, 2.38 to 3.44), 2.88 (CI, 2.23 to 3.71), and 2.80 (CI, 1.94 to 4.03), respectively. Increasing HbA1c levels were associated with the study's secondary outcomes: large for gestational age, hypoglycemia, respiratory distress, low Apgar score, neonatal death, and stillbirth.

LIMITATION

Because HbA1c levels were registered annually at routine visits, they were not available for all pregnant women with T1D.

CONCLUSION

The risk for preterm birth was strongly linked to periconceptional HbA1c levels. Women with HbA1c levels consistent with recommended target levels also were at increased risk.

PRIMARY FUNDING SOURCE

Swedish Diabetes Foundation.

Outcomes of type 1 diabetes mellitus in pregnancy; effect of excessive gestational weight gain and hyperglycaemia on fetal growth

AIMS

To study pregnancy outcomes in patients with type 1 diabetes mellitus (T1DM) and the factors associated with poor outcomes.

METHODS

A retrospective study of 110 patients with T2DM who attended our diabetes in pregnancy clinic at the Women's Wellness and Research centre, Doha, between March 2015 and December 2016 and 1419 normoglycaemic controls.

RESULTS

There was no difference in age, weight, and BMI between the two groups. The incidence of macrosomia, shoulder dystocia and stillbirth were similar in the two groups while that of pre-term labour, pre-eclampsia, Caesarean section (CS), large for gestational age (LGA), neonatal ICU (NICU) admission and neonatal hypoglycaemia were significantly higher in the T1DM than in the control group. From a multivariate regression analysis, excessive gestational weight gain was associated with increased risk of LGA (OR 4.53; 95% CI [1.42-14.25]). Last trimester HBA1c was associated with increased risk for macrosomia [OR 2.46, 95% CI [1.03-5.86)]; LGA [ OR 3.25, 95% CI [1.65-6.40)]; increased risk for C-section (OR 1.96, 95% CI [1.12-3.45]), and increased risk of NICU admission (OR 2.46, 95% CI [1.04-5.86]). The changes in HBA1C between the first and last trimester HBA1c was associated with a reduction in the risk of LGA [OR 0.46, 95% CI [(0.28-0.75)] CONCLUSION: T1DM in pregnancy is associated with adverse pregnancy outcomes compared to the general population. Reducing gestational weight gain and improving glycaemic control might improve pregnancy outcomes.

A Feasibility Study of Paired Continuous Glucose Monitoring Intrapartum and in the Newborn in Pregnancies Complicated by Type 1 Diabetes

AIM

To describe the continuous glucose monitoring (CGM) profiles of type 1 diabetes (T1D) offspring in the early neonatal period and its association with maternal intrapartum glucose control.

METHODS

A prospective observational study of T1D pregnant women and their neonatal offspring. Women had a CGM sensor inserted 2-3 days before delivery. Infants had a masked CGM sensor inserted as soon as possible after delivery. Maternal glycemic outcomes were time-in-target (70-140 mg/dL [3.9-7.8 mmol/L]), hyperglycemia >140 mg/dL (7.8 mmol/L), and mean CGM glucose during the 24 h preceding delivery. Neonatal outcomes included lowest recorded blood glucose concentration, and CGM measures (glucose <47 mg/dL [2.6 mmol/L], time-in-target (47-144 mg/dL [2.6-8.0 mmol/L]), glucose standard deviation [SD]) during the first 72 h of life.

RESULTS

Data were available for 16 mother-infant pairs. Mothers had a mean age (SD) 32.3 (4.3) years, T1D duration 17.6 (6.8) years, first antenatal glycated hemoglobin 7.4 (0.8)% (57 [8.5] mmol/mol). In the 24 h preceding delivery, mothers spent mean (SD) 72 (20)% time-in-target (70-140 mg/dL [3.9-7.8 mmol/L]), 19 (15)% time >140 mg/dL (7.8 mmol/L), and 9 (9)% time <70 mg/dL (3.9 mmol/L) with mean (SD) CGM glucose 113 (9) mg/dL (6.3 [0.7] mmol/L). Fifteen infants (93.8%) had ≥1 blood glucose concentration <47 mg/dL (2.6 mmol/L), and five had ≥1 blood glucose concentration <18 mg/dL (1.0 mmol/L). The mean infant CGM glucose on days 1, 2, and 3 of life was 63 (14), 67 (13), 76 (11) mg/dL (3.5 [0.8], 3.7 [0.7], and 4.2 [0.6] mmol/L). Four infants (25%) spent >50% time with CGM glucose levels <47 mg/dL (2.6 mmol/L) on day 1.

CONCLUSIONS

CGM detected widespread neonatal hypoglycemia, even among mothers with good intrapartum glucose control.

Type 2 diabetes mellitus in pregnancy: The impact of maternal weight and early glycaemic control on outcomes

OBJECTIVES

To study the pregnancy outcomes in women with type 2 diabetes mellitus (T2DM) and to relate these to maternal risk factors.

METHODS

We conducted a retrospective study of 419 women with T2DM (index group)- who attended our diabetes in pregnancy clinic at the Hamad Women's Hospital, Doha, between March 2015 and December 2016 -and 1419 normoglycaemic women (control group).

RESULTS

Compared with the controls, T2DM women were older (mean age 34.7 ± 6.9 vs 29.6 ± 5.5 years; p < 0.001) and had a higher BMI (34.5 ± 6.7 vs 28.8 ± 6.1 kg/m2; p < 0.001). The incidence of macrosomia, shoulder dystocia and stillbirth were similar in the two groups, while that of pre-term labour, pre-eclampsia, caesarean section (CS), large for gestational age (LGA), neonatal ICU (NICU) admission, and neonatal hypoglycaemia were significantly higher in the T2DM compared to the control group (p < 0.05). Multivariate regression analysis showed that first trimester HbA1C was associated with an increased risk of LGA (OR 1.17; 95% CI [1.01-1.36]), pre-eclampsia (OR 1.26; 95% CI [1.02-1.54]), neonatal hypoglycaemia (OR 1.32; 95% CI 1.10-1.60) and NICU admission (OR 1.32; 95% CI 1.10-1.60). Pre-pregnancy BMI was associated with increased risk of LGA (OR 1.04; 95%CI [1.00-1.08]), macrosomia (OR 1.06; 95%CI [1.00-1.12]) and CS (OR 1.05; 95% CI [1.01-1.09]). Last trimester HbA1c was associated with an increased risk of LGA [OR 1.53, 95% CI [1.13-2.10)] and CS (OR 1.37, 95% CI [1.01-1.87]).

CONCLUSION

T2DM is associated with adverse pregnancy outcomes compared to the normal control in Qatar. Maternal obesity and glycaemic control before and during pregnancy are the main determinants of pregnancy outcomes in women with T2DM.

Implementation of national screening guidelines for gestational diabetes: A national survey of maternity units in England

AIMS

To describe national implementation of gestational diabetes (GDM) risk-factor based screening guidelines, and barriers to implementation relating to maternal body mass index (BMI).

METHODS

National online survey of NHS Trusts offering maternity services in England. A questionnaire was emailed to clinical staff involved in care of pregnant women assessing compliance with NICE guidelines for risk-factor based screening, BMI thresholds for offering OGTT and barriers to offering OGTT to women with BMI ≥ 30 kg/m2.

RESULTS

Health professionals from 113 (84%) of NHS Trusts in England responded to the survey. Most Trusts (81%) offered OGTT at 26-28 weeks gestation to women with selected risk factors for GDM. However, almost 40% of Trusts were not fully compliant with NICE screening criteria for all risk factors, mainly due to not offering OGTT to women with previous GDM (25% of Trusts), BMI ≥ 30 kg/m2 or ethnic minority groups (22% of Trusts). The main barriers to compliance with the BMI threshold were lack of capacity, resource and funding given the high prevalence of maternal obesity. Forty one percent of Trusts used diagnostic thresholds for GDM which differed from NICE recommendations.

CONCLUSIONS

Additional resources are required for NHS Trusts to fully implement and sustain risk-factor screening, especially for women with previous GDM, BMI ≥ 30 kg/m2 and ethnic minority groups.

Pumps or Multiple Daily Injections in Pregnancy Involving Type 1 Diabetes: A Prespecified Analysis of the CONCEPTT Randomized Trial

OBJECTIVE

To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT).

RESEARCH DESIGN AND METHODS

This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA_1c. The primary outcome was change in HbA_1c from randomization to 34 weeks' gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes.

RESULTS

At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA_1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA_1c (-0.55 ± 0.59 vs. -0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA_1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02).

CONCLUSIONS

In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.

Women's Experiences of Day-and-Night Closed-Loop Insulin Delivery During Type 1 Diabetes Pregnancy

AIMS

Closed-loop insulin delivery has the potential to improve day-to-day glucose control in type 1 diabetes pregnancy. However, the psychosocial impact of day-and-night usage of automated closed-loop systems during pregnancy is unknown. Our aim was to explore women's experiences and relationships between technology experience and levels of trust in closed-loop therapy.

METHODS

We recruited 16 pregnant women with type 1 diabetes to a randomized crossover trial of sensor-augmented pump therapy compared to automated closed-loop therapy. We conducted semistructured qualitative interviews at baseline and follow-up. Findings from follow-up interviews are reported here.

RESULTS

Women described benefits and burdens of closed-loop systems during pregnancy. Feelings of improved glucose control, excitement and peace of mind were counterbalanced by concerns about technical glitches, CGM inaccuracy, and the burden of maintenance requirements. Women expressed varied but mostly high levels of trust in closed-loop therapy.

CONCLUSIONS

Women displayed complex psychosocial responses to day-and-night closed-loop therapy in pregnancy. Clinicians should consider closed-loop therapy not just in terms of its potential impact on biomedical outcomes but also in terms of its impact on users' lives.

The need for appropriate registration of pregnancy outcomes under newer oral glucose-lowering therapies

Because of the increase in type 2 diabetes (T2DM) in young adults, women of childbearing age are frequently treated with newer glucose-lowering therapies, and an increase in unintentional exposure to therapies unapproved for use during pregnancy is expected. The clinician is left with the dilemma of deciding between discontinuation of a novel agent that is providing excellent glycaemic control, while switching to other agents may cause deterioration of glycaemia, and continued use of novel agents that may have uncertain effects on the unborn child. For T2DM, pregnancy data are collected only via spontaneous reporting systems. Therefore, we evaluated the available data on pregnancy outcomes under newer glucose-lowering agents in pharmaceutical safety databases. We found that data on pregnancy outcomes with new glucose-lowering agents in T2DM are scarce, with a high risk of bias towards negative outcomes, limiting their usefulness in robustly assessing safety. Because of the lack of information at present, these agents are not recommended for use during pregnancy or when planning pregnancy. To better guide clinical practice, structured systems of assessing pregnancy outcomes in women receiving these novel agents are urgently needed.

No further improvement in pregnancy-related outcomes in the offspring of mothers with pre-gestational diabetes in Bavaria, Germany, between 2001 and 2016

AIMS

To investigate whether there has been further improvement in the risk of adverse outcomes in pregnancies in women with diabetes during 2008-2016 in Bavaria, Germany.

METHODS

Using cross-sectional data on all 1716 170 deliveries in Bavarian hospitals between 2001 and 2016, we assessed the risks of stillbirth, early neonatal death, preterm delivery, large for gestational age, malformations, low Apgar score and low umbilical cord pH by maternal group with diabetes (gestational, pre-gestational, or none) separately for 2001-2007 and 2008-2016. We also investigated the associations of specific risk factors such as maternal smoking with respect to early mortality and malformations in each group with diabetes during 2008-2016.

RESULTS

No further reduction in the risk for any adverse outcome in mothers with pre-gestational diabetes and their offspring during 2008-2016 was observed. Maternal smoking, multiple delivery and substandard antenatal care were the strongest additional predictors of both early perinatal mortality and malformations for mothers with pre-gestational diabetes. The respective risks were lower and also decreased over time for mothers with gestational diabetes.

CONCLUSIONS

No significant improvement has been achieved in the management of pregnancies affected by pre-gestational diabetes during the last decade. The apparent risk reductions in women with gestational diabetes may partly be due to a change in diagnostic criteria over time. Women with pre-gestational diabetes who smoke, carry more than one child, or are not regularly seen during pregnancy, may need particular attention.

Advances in Closed-Loop Insulin Delivery Systems in Patients with Type 1 Diabetes

To provide a current review of closed-loop insulin delivery or artificial pancreas (AP) as therapy for people with type 1 diabetes mellitus (T1D) RECENT FINDINGS: The Medtronic Minimed 670G AP system has been in use in clinical practice since March 2017. Currently, Medtronic is conducting a large randomized clinical trial to evaluate its efficacy further in T1D. Simultaneously, the NIH has funded four research consortia to accelerate progress to approval of other AP and decision support systems. Several research groups are currently developing next-generation AP systems, with a number of companies moving toward releasing closed-loop systems in the future. AP systems are also being tested in select populations such as hypoglycemia-unaware T1D and pregnant T1D. AP research is rapidly advancing. The clinical range of AP will be expanded in the next decade.

Intensive Glycemic Treatment During Type 1 Diabetes Pregnancy: A Story of (Mostly) Sweet Success!

Studies from Scotland and Canada confirm large increases in the incidence of pregnancies complicated by pregestational type 1 diabetes (T1D). With this increased antenatal workload comes more specialization and staff expertise, which may be important as diabetes technology use increases. While euglycemia remains elusive and obstetrical intervention (earlier delivery, increased operative deliveries) is increasing, there have been some notable successes in the past 5-10 years. These include a decline in the rates of congenital anomaly (Canada) and stillbirths (U.K.) and substantial reductions in both maternal hypoglycemia (both moderate and severe) across many countries. However, pregnant women with T1D still spend ∼30-45% of the time (8-11 h/day) hyperglycemic during the second and third trimesters. The duration of maternal hyperglycemia appears unchanged in routine clinical care over the past decade. This ongoing fetal exposure to maternal hyperglycemia likely explains the persistent rates of large for gestational age (LGA), neonatal hypoglycemia, and neonatal intensive care unit (NICU) admissions in T1D offspring. The Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT) found that pregnant women using real-time continuous glucose monitoring (CGM) spent 5% less time (1.2 h/day) hyperglycemic during the third trimester, with clinically relevant reductions in LGA, neonatal hypoglycemia, and NICU admissions. This article will review the progress in our understanding of the intensive glycemic treatment of T1D pregnancy, focusing in particular on the recent technological advances in CGM and automated insulin delivery. It suggests that even with advanced diabetes technology, optimal maternal dietary intake is needed to minimize the neonatal complications attributed to postprandial hyperglycemia.

Temporal changes in characteristics and outcomes among pregnant women with pre-gestational diabetes

OBJECTIVE

To evaluate pregnancy outcomes among women with pre-gestational diabetes.

METHODS

Retrospective analysis of pregnant women with type 1 or type 2 diabetes attending a university hospital in Brazil. Maternal characteristics and pregnancy outcomes were compared among deliveries between May 1, 2005, and December 31, 2010, and between January 1, 2011, and December 31, 2015. Risks were calculated by Poisson regression.

RESULTS

In total 220 women were included. Type 1 diabetes was more frequent in 2005-2010 than in 2011-2015, and type 2 diabetes was more frequent in 2011-2015 (P=0.005). History of macrosomia (P=0.011), hypertensive disorders of pregnancy (P=0.015), and pre-gestational excess weight (body mass index >25 kg/m² ; P=0.003) was more frequent in 2011-2015. For women with type 1 diabetes, pre-gestational weight (P=0.007) and glycated hemoglobin (P=0.026) were higher in 2011-2015. For women with type 2 diabetes, previous hypertensive disorders of pregnancy (P=0.032) were more prevalent and family history of diabetes (P<0.001) less prevalent in 2011-2015. Adverse pregnancy outcomes were similar for type 1 and type 2, and across both periods.

CONCLUSION

Type 2 diabetes became more common over the two time periods and women with type 1 diabetes had higher pre-gestational weight. Perinatal outcomes were similar.

Periconception glycaemic control in women with type 1 diabetes and risk of major birth defects: population based cohort study in Sweden

OBJECTIVE

To examine the association between maternal type 1 diabetes and the risk of major birth defects according to levels of glycated haemoglobin (HbA1C) within three months before or after estimated conception.

DESIGN

Population based historical cohort study using nationwide health registers.

SETTING

Sweden, 2003-15.

PARTICIPANTS

2458 singleton liveborn infants of mothers with type 1 diabetes and a glycated haemoglobin measurement within three months before or after estimated conception and 1 159 865 infants of mothers without diabetes.

MAIN OUTCOME MEASURES

Major cardiac and non-cardiac birth defects according to glycated haemoglobin levels.

RESULTS

122 cases of major cardiac defects were observed among 2458 infants of mothers with type 1 diabetes. Compared with 15 cases of major cardiac defects per 1000 infants of mothers without diabetes, the rates among infants of mothers with type 1 diabetes were 33 per 1000 for a glycated haemoglobin level of <6.5% (adjusted risk ratio 2.17, 95% confidence interval 1.37 to 3.42), 49 per 1000 for 6.5% to <7.8% (3.17, 2.45 to 4.11), 44 per 1000 for 7.8% to <9.1% (2.79, 1.90 to 4.12), and 101 per 1000 for ≥9.1% (6.23, 4.32 to 9.00). The corresponding adjusted risk differences were 17 (5 to 36), 32 (21 to 46), 26 (13 to 46), and 77 (49 to 118) cases of major cardiac defects per 1000 infants, respectively. 50 cases of major non-cardiac defects were observed among infants of mothers with type 1 diabetes. Compared with 18 cases of major non-cardiac defects per 1000 infants of mothers without diabetes, the rates among infants of mothers with type 1 diabetes were 22 per 1000 for a glycated haemoglobin level of <6.5% (adjusted risk ratio 1.18, 0.68 to 2.07), 19 per 1000 for 6.5% to <7.8% (1.01, 0.66 to 1.54), 17 per 1000 for 7.8% to <9.1% (0.89, 0.46 to 1.69), and 32 per 1000 for ≥9.1% (1.68, 0.85 to 3.33).

CONCLUSION

Among liveborn infants of mothers with type 1 diabetes, increasingly worse glycaemic control in the three months before or after estimated conception was associated with a progressively increased risk of major cardiac defects. Even with glycated haemoglobin within target levels recommended by guidelines (<6.5%), the risk of major cardiac defects was increased more than twofold. The risk of major non-cardiac defects was not statistically significantly increased at any of the four glycated haemoglobin levels examined; the study had limited statistical power for this outcome and was based on live births only.

Community-based pre-pregnancy care programme improves pregnancy preparation in women with pregestational diabetes

AIMS/HYPOTHESIS

Women with diabetes remain at increased risk of adverse pregnancy outcomes associated with poor pregnancy preparation. However, women with type 2 diabetes are less aware of and less likely to access pre-pregnancy care (PPC) compared with women with type 1 diabetes. We developed and evaluated a community-based PPC programme with the aim of improving pregnancy preparation in all women with pregestational diabetes.

METHODS

This was a prospective cohort study comparing pregnancy preparation measures before and during/after the PPC intervention in women with pre-existing diabetes from 1 June 2013 to 28 February 2017. The setting was 422 primary care practices and ten National Health Service specialist antenatal diabetes clinics. A multifaceted approach was taken to engage women with diabetes and community healthcare teams. This included identifying and sending PPC information leaflets to all eligible women, electronic preconception care templates, online education modules and resources, and regional meetings and educational events. Key outcomes were preconception folic acid supplementation, maternal HbA_1c level, use of potentially harmful medications at conception and gestational age at first presentation, before and during/after the PPC programme.

RESULTS

A total of 306 (73%) primary care practices actively participated in the PPC programme. Primary care databases were used to identify 5075 women with diabetes aged 18-45 years. PPC leaflets were provided to 4558 (89.8%) eligible women. There were 842 consecutive pregnancies in women with diabetes: 502 before and 340 during/after the PPC intervention. During/after the PPC intervention, pregnant women with type 2 diabetes were more likely to achieve target HbA_1c levels ≤48 mmol/mol (6.5%) (44.4% of women before vs 58.5% of women during/after PPC intervention; p = 0.016) and to take 5 mg folic acid daily (23.5% and 41.8%; p = 0.001). There was an almost threefold improvement in 'optimal' pregnancy preparation in women with type 2 diabetes (5.8% and 15.1%; p = 0.021). Women with type 1 diabetes presented for earlier antenatal care during/after PPC (54.0% vs 67.3% before 8 weeks' gestation; p = 0.003) with no other changes.

CONCLUSIONS/INTERPRETATION

A pragmatic community-based PPC programme was associated with clinically relevant improvements in pregnancy preparation in women with type 2 diabetes. To our knowledge, this is the first community-based PPC intervention to improve pregnancy preparation for women with type 2 diabetes.

DATA AVAILABILITY

Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-pregnancy-in-diabetes-audit .

Day-and-Night Closed-Loop Insulin Delivery in a Broad Population of Pregnant Women With Type 1 Diabetes: A Randomized Controlled Crossover Trial

OBJECTIVE

Despite advances in technology, optimal glucose control remains elusive and neonatal complications remain ubiquitous in type 1 diabetes (T1D) pregnancy. Our aim was to examine the safety, efficacy, and longer-term feasibility of day-and-night closed-loop insulin delivery.

RESEARCH DESIGN AND METHODS

We recruited 16 pregnant women (mean [SD]: age 32.8 [5.0] years, T1D duration 19.4 [10.2] years, HbA_1c 8.0% [1.1], and BMI 26.6 [4.4] kg/m²) to an open-label, randomized, crossover trial. Participants completed 28 days of closed-loop and sensor-augmented pump (SAP) insulin delivery separated by a washout period. Afterward, participants could continue to use the closed-loop system up to 6 weeks postpartum. The primary end point was the proportion of time with glucose levels within the target range (63-140 mg/dL).

RESULTS

The proportion of time with glucose levels within target was comparable during closed-loop and SAP insulin delivery (62.3 vs. 60.1% [95% CI -4.1 to 8.3]; P = 0.47). Mean glucose and time spent hyperglycemic >140 mg/dL also did not differ (131.4 vs. 131.4 mg/dL [P = 0.85] and 36.6 vs. 36.1% [P = 0.86], respectively). During closed-loop, fewer hypoglycemic episodes occurred (median 8 [range 1-17] vs. 12.5 [1-53] over 28 days; P = 0.04) and less time at <63 mg/dL (1.6 vs. 2.7%; P = 0.02). Hypoglycemia <50 mg/dL (0.24 vs. 0.47%; P = 0.03) and low blood glucose index (1.0 vs. 1.4; P = 0.01) were lower. Less nocturnal hypoglycemia (2300-0700 h) during closed-loop therapy (1.1 vs. 2.7%; P = 0.008) and a trend toward higher overnight time in target (67.7 vs. 60.6%; P = 0.06) were found.

CONCLUSIONS

Closed-loop insulin delivery was associated with comparable glucose control and significantly less hypoglycemia than SAP therapy. Larger, longer-duration multicenter trials are now indicated to determine clinical efficacy of closed-loop insulin delivery in T1D pregnancy and the impact on neonatal outcomes.

Adaptability of Closed Loop During Labor, Delivery, and Postpartum: A Secondary Analysis of Data from Two Randomized Crossover Trials in Type 1 Diabetes Pregnancy

Tight glucose control during labor and delivery is recommended for pregnant women with type 1 diabetes. This can be challenging to achieve using the current treatment modalities. The automated nature of closed loop and its ability to adapt to real-time glucose levels make it well suited for use during labor, delivery, and the immediate postpartum period. We report observational data of participants from two randomized crossover trials who chose to continue using closed loop during labor, delivery, and postpartum. Labor was defined as the 24 h before delivery and postpartum as the 48 h after delivery. The glucose target range during pregnancy was 3.5-7.8 mmol/L (63-140 mg/dL) and 3.9-10 mmol/L (70-180 mg/dL) after delivery. Twenty-seven (84.4%) of the potential 32 trial participants used closed loop through labor, delivery, and postpartum. Use of closed loop was associated with 82.0% (interquartile range [IQR] 49.3, 93.0) time-in-target range during labor and delivery and a mean glucose of 6.9 ± 1.4 mmol/L (124 ± 25 mg/dL). Closed loop performed well throughout vaginal, elective, and emergency cesarean section deliveries. Postpartum, women spent 83.3% (IQR 75.2, 94.6) time-in-target range (3.9-10.0 mmol/L [70-180 mg/dL]), with a mean glucose of 7.2 ± 1.4 mmol/L (130 ± 25 mg/dL). There was no difference in maternal glucose concentration between mothers of infants with and without neonatal hypoglycemia (6.9 ± 1.6 mmol/L and 6.8 ± 1.1 mmol/L [124 ± 29 mg/dL and 122 ± 20 mg/dL] respectively; P = 0.84). Automated closed-loop insulin delivery is feasible during hospital admissions for labor, delivery, and postpartum. Larger scale studies are needed to evaluate its efficacy compared with current clinical approaches as well as understand how women and healthcare providers will adopt this technology.

Determinants of a good perinatal outcome in 588 pregnancies in women with type 1 diabetes

AIM

This study assessed pregnancy outcomes in women with type 1 diabetes (T1D) over the last 15 years and identified modifiable factors associated with good perinatal outcomes.

METHODS

Pregnancy outcomes were prospectively assessed in this cohort study of 588 singleton pregnancies (441 women) managed by standardized care from 2000 to 2014. A good perinatal outcome was defined as the uncomplicated delivery of a normally formed, non-macrosomic, full-term infant with no neonatal morbidity. Factors associated with good perinatal outcomes were identified by logistic regression.

RESULTS

The rate of severe congenital malformations was 1.5%, and 0.7% for perinatal mortality. The most frequent perinatal complications were macrosomia (41%), preterm delivery (16%) and neonatal hypoglycaemia (11%). Shoulder dystocia occurred in 2.6% of cases, but without sequelae. Perinatal outcomes were good in 254 (44%) pregnancies, and were associated with lower maternal HbA_1c values at delivery [adjusted odds ratio (aOR): 2.78, 95% CI: 2.04-3.70, for each 1% (11mmol/mol) absolute decrease], lower gestational weight gains (aOR: 1.06, 95% CI: 1.02-1.10) and absence of preeclampsia (aOR: 2.63, 95% CI: 1.09-6.25). The relationship between HbA_1c at delivery and a good perinatal outcome was continuous, with no discrimination threshold.

CONCLUSION

In our study, rates of severe congenital malformations and perinatal mortality were similar to those of the general population. Less severe complications, mainly macrosomia and late preterm delivery, persisted. Also, our study identified modifiable risk factors that could be targeted to further improve the prognosis of pregnancy in T1D.

Diabetes and pregnancy: national trends over a 15 year period

AIMS/HYPOTHESIS

We aimed to examine time trends in national perinatal outcomes in pregnancies complicated by pre-existing type 1 or type 2 diabetes.

METHODS

We analysed episode-level data on all obstetric inpatient delivery events (live or stillbirth) between 1 April 1998 and 31 March 2013 (n = 813,921) using the Scottish Morbidity Record (SMR02). Pregnancies to mothers with type 1 (n = 3229) and type 2 (n = 1452) diabetes were identified from the national diabetes database (Scottish Care Information-Diabetes), and perinatal outcomes were compared among women with type 1 diabetes, type 2 diabetes and those without diabetes.

RESULTS

The number of pregnancies complicated by diabetes increased significantly, by 44% in type 1 diabetes and 90% in type 2 diabetes, across the 15 years examined, to rates of 1 in 210 and 1 in 504 deliveries, respectively. Compared with women without diabetes, delivery occurred 2.6 weeks earlier (type 1 diabetes 36.7 ± 2.3 weeks) and 2 weeks earlier (type 2 diabetes 37.3 ± 2.4 weeks), respectively, showing significant reductions for both type 1 (from 36.7 weeks to 36.4 weeks, p = 0.03) and type 2 (from 38.0 weeks to 37.2 weeks, p < 0.001) diabetes across the time period. The proportions of preterm delivery were markedly increased in women with diabetes (35.3% type 1 diabetes, 21.8% type 2 diabetes, 6.1% without diabetes; p < 0.0001), and these proportions increased with time for both groups (p < 0.005). Proportions of elective Caesarean sections (29.4% type 1 diabetes, 30.5% type 2 diabetes, 9.6% without diabetes) and emergency Caesarean sections (38.3% type 1 diabetes, 29.1% type 2 diabetes, 14.6% without diabetes) were greatly increased in women with diabetes and increased over time except for stable rates of emergency Caesarean section in type 1 diabetes. Gestational age-, sex- and parity-adjusted z score for birthweight (1.33 ± 1.34; p < 0.001) were higher in type 1 diabetes and increased over time from 1.22 to 1.47 (p < 0.001). Birthweight was also increased in type 2 diabetes (0.94 ± 1.34; p < 0.001) but did not alter with time. There were 65 perinatal deaths in offspring of mothers with type 1 diabetes and 39 to mothers with type 2 diabetes, representing perinatal mortality rates of 20.1 (95% CI 14.7, 24.3) and 26.9 (16.7, 32.9) per 1000 births, respectively, and rates 3.1 and 4.2 times, respectively, those observed in the non-diabetic population (p < 0.001). Stillbirth rates in type 1 and type 2 diabetes were 4.0-fold and 5.1-fold that in the non-diabetic population (p < 0.001). Perinatal mortality and stillbirth rates showed no significant fall over time despite small falls in the rates for the non-diabetic population.

CONCLUSIONS/INTERPRETATION

Women with diabetes are receiving increased intervention in pregnancy (earlier delivery, increased Caesarean section rates), but despite this, higher birthweights are being recorded. Improvements in rates of stillbirth seen in the general population are not being reflected in changes in stillbirth or perinatal mortality in our population with diabetes.

Diabetes in pregnancy: a new decade of challenges ahead

Every 10 years, the Diabetic Pregnancy Study Group, a study group of the EASD, conducts an audit meeting to review the achievements of the preceding decade and to set the directions for research and clinical practice improvements for the next decade. The most recent meeting focused on the following areas: improving pregnancy outcomes for women with pregestational type 1 diabetes and type 2 diabetes; the influence of obesity and gestational diabetes on pregnancy outcomes; the determinants and assessment of fetal growth and development; and public health issues, including consideration of transgenerational consequences and economic burden. The audit meeting also considered the likely impact of 'omics' on research within the field and the potential of these technologies to enable precision-medicine approaches to management. Through sharing of the findings and ideas of audit meeting participants, the DPSG hopes to promote networking, research and advances in clinical care, to improve outcomes for all women and their offspring affected by diabetes and obesity in pregnancy.

Continuous glucose monitoring in pregnant women with Type 1 diabetes: benefits for mothers, using pumps or pens, and their babies

AIMS

To review the current literature on the use of continuous glucose monitoring during pregnancy in women with Type 1 diabetes.

METHODS

We searched the literature for randomized controlled trials using continuous glucose monitoring during pregnancy in women with Type 1 diabetes.

RESULTS

Three randomized trials were found and discussed in this review. One UK study found a reduction in large-for-gestational-age infants; however, only masked continuous glucose monitoring was used in that study. A Danish study used intermittent real-time continuous glucose monitoring and found no differences. The present authors conducted the CONCEPTT trial, in which pregnant women and women planning pregnancy were randomized to receive continuous glucose monitoring or standard care. We found a greater drop in HbA_1c , more time spent in the target range, and a reduction in some adverse neonatal outcomes in women using continuous glucose monitoring. Numbers-needed-to-treat to prevent a large-for-gestational-age infant, a neonatal intensive care unit admission for >24 h, and a neonatal hypoglycaemia event were low. These findings were seen in both injection and pump users and across all countries. Possible reasons for differences in study findings are discussed. In addition, several issues need further study. Glycaemic variability and differences in dietary intake may also have played a role. Despite excellent glycaemic control, babies continue to be large. More research is needed to understand the role of glucose targets and the dynamic placental processes involved in fetal growth.

CONCLUSIONS

The use of continuous glucose monitoring in women with Type 1 diabetes in pregnancy is associated with improved glycaemic control and neonatal outcomes. Further research examining the glycaemic and non-glycaemic variables involved in fetal growth and the cost-benefit of using continuous glucose monitoring in pregnancy is warranted.

Diastolic blood pressure is a potentially modifiable risk factor for preeclampsia in women with pre-existing diabetes

AIMS

To identify early clinical, modifiable risk factors for preeclampsia present at first antenatal visit and assess the prevalence of pregnancy-related hypertensive disorders in women with pre-existing diabetes treated with tight glycemic and blood pressure (BP) control.

METHODS

A population-based cohort study of 494 women with pre-existing diabetes (307 and 187 women with type 1 and type 2 diabetes, respectively), included at their first antenatal visit from 2012 to 2016. The prevalence of chronic hypertension (without diabetic nephropathy or microalbuminuria), gestational hypertension and preeclampsia was recorded. Diabetic microangiopathy included presence of nephropathy, microalbuminuria and/or retinopathy. Treatment target was BP <135/85 mmHg.

RESULTS

HbA1c was 6.9 ± 2.4% (50 ± 12 mmol/mol) at first antenatal visit and 6.0 ± 0.6% (43 ± 6 mmol/mol) before delivery with no differences between women with type 1 and type 2 diabetes. At the first antenatal visit, the prevalence of microalbuminuria was 6% (6% vs. 6%), nephropathy 2% (1% vs. 2%) and chronic hypertension 6% (3% vs. 10%, p = 0.03). Gestational hypertension developed in 8% (9% vs. 6%) and preeclampsia developed in 8% (9% vs. 7%). Presence of diabetic microangiopathy (adjusted odds ratio (OR) 4.35 (confidence interval 2.12-8.93)) and diastolic BP (adjusted OR 1.72 per 10 mmHg (1.05-2.82)) at the first antenatal visit were independent risk factors for preeclampsia.

CONCLUSIONS

At the first antenatal visit, diastolic BP was the only independent, potentially modifiable risk factor for preeclampsia in women with pre-existing diabetes in the context of tight glycemic and BP control. One out of four women had hypertensive disorders during pregnancy.

Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes

Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA_1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15-50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes.

Emerging Technologies for the Management of Type 1 Diabetes in Pregnancy

PURPOSE OF REVIEW

The purpose of the study is to discuss emerging technologies available in the management of type 1 diabetes in pregnancy.

RECENT FINDINGS

The latest evidence suggests that continuous glucose monitoring (CGM) should be offered to all women on intensive insulin therapy in early pregnancy. Studies have additionally demonstrated the ability of CGM to help gain insight into specific glucose profiles as they relate to glycaemic targets and pregnancy outcomes. Despite new studies comparing insulin pump therapy to multiple daily injections, its effectiveness in improving glucose and pregnancy outcomes remains unclear. Sensor-integrated insulin delivery (also called artificial pancreas or closed-loop insulin delivery) in pregnancy has been demonstrated to improve time in target and performs well despite the changing insulin demands of pregnancy. Emerging technologies show promise in the management of type 1 diabetes in pregnancy; however, research must continue to keep up as technology advances. Further research is needed to clarify the role technology can play in optimising glucose control before and during pregnancy as well as to understand which women are candidates for sensor-integrated insulin delivery.

Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial

BACKGROUND

Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes.

METHODS

In this multicentre, open-label, randomised controlled trial, we recruited women aged 18-40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA_1c). The primary outcome was change in HbA_1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527.

FINDINGS

Between March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA_1c in pregnant women using CGM (mean difference -0·19%; 95% CI -0·34 to -0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most common adverse events were skin reactions occurring in 49 (48%) of 103 CGM participants and eight (8%) of 104 control participants during pregnancy and in 23 (44%) of 52 CGM participants and five (9%) of 57 control participants in the planning pregnancy trial. The most common serious adverse events were gastrointestinal (nausea and vomiting in four participants during pregnancy and three participants planning pregnancy).

INTERPRETATION

Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use.

FUNDING

Juvenile Diabetes Research Foundation, Canadian Clinical Trials Network, and National Institute for Health Research.