15. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2022

Molecular biomarkers for gestational diabetes mellitus and postpartum diabetes

ABSTRACT

Gestational diabetes mellitus (GDM) is a growing public health problem worldwide that threatens both maternal and fetal health. Identifying individuals at high risk for GDM and diabetes after GDM is particularly useful for early intervention and prevention of disease progression. In the last decades, a number of studies have used metabolomics, genomics, and proteomic approaches to investigate associations between biomolecules and GDM progression. These studies clearly demonstrate that various biomarkers reflect pathological changes in GDM. The established markers have potential use as screening and diagnostic tools in GDM and in postpartum diabetes research. In the present review, we summarize recent studies of metabolites, single-nucleotide polymorphisms, microRNAs, and proteins associated with GDM and its transition to postpartum diabetes, with a focus on their predictive value in screening and diagnosis.

Preconception Counseling in Women With Diabetes: The SEARCH for Diabetes in Youth Study

Preconception counseling is recommended for all women with diabetes starting at puberty to convey the importance of optimal diabetes management for maternal and fetal outcomes. This study included 622 female participants from the SEARCH for Diabetes in Youth study with a mean age of 22.2 years (range 14-35 years). Only 53.7% reported ever receiving preconception counseling, which was significantly lower among women seeing pediatric providers than those seeing adult or all-age providers. Older age and history of prior pregnancy were associated with increased odds of reporting having received preconception counseling. Identification of barriers to delivering preconception counseling to young females with diabetes and strategies to overcome them are needed to reduce the risk for pregnancy complications and adverse offspring health outcomes.

Metformin: When Should We Fear Lactic Acidosis?

Metformin, a molecule belonging to the biguanide family, represents one of the most commonly prescribed medications for the treatment of diabetes mellitus in the world. Over the sixty years during which it has been used, many benefits have been described, which are not limited to the treatment of diabetes mellitus. However, since metformin is similar to other members of the same drug family, there is still much concern regarding the risk of lactic acidosis. This article aims to highlight the correlation between the use of metformin and the onset of renal damage or lactic acidosis. Metformin-associated lactic acidosis exists; however, it is rare. The appropriate use of the drug, under safe conditions, induces benefits without risks.

Updates for hyperglycemia in pregnancy: the ongoing journey for maternal-neonatal health

We summarize updates of hyperglycemia in pregnancy as well as debate of diagnosis of criteria of gestational diabetes. We also point out several unsovled issues of gestataional diabetes that remain further investigations.

Feasibility of Closed-Loop Insulin Delivery with a Pregnancy-Specific Zone Model Predictive Control Algorithm

Objective: Evaluating the feasibility of closed-loop insulin delivery with a zone model predictive control (zone-MPC) algorithm designed for pregnancy complicated by type 1 diabetes (T1D). Research Design and Methods: Pregnant women with T1D from 14 to 32 weeks gestation already using continuous glucose monitor (CGM) augmented pump therapy were enrolled in a 2-day multicenter supervised outpatient study evaluating pregnancy-specific zone-MPC based closed-loop control (CLC) with the interoperable artificial pancreas system (iAPS) running on an unlocked smartphone. Meals and activities were unrestricted. The primary outcome was the CGM percentage of time between 63 and 140 mg/dL compared with participants' 1-week run-in period. Early (2-h) postprandial glucose control was also evaluated. Results: Eleven participants completed the study (age: 30.6 ± 4.1 years; gestational age: 20.7 ± 3.5 weeks; weight: 76.5 ± 15.3 kg; hemoglobin A1c: 5.6% ± 0.5% at enrollment). No serious adverse events occurred. Compared with the 1-week run-in, there was an increased percentage of time in 63-140 mg/dL during supervised CLC (CLC: 81.5%, run-in: 64%, P = 0.007) with less time >140 mg/dL (CLC: 16.5%, run-in: 30.8%, P = 0.029) and time <63 mg/dL (CLC: 2.0%, run-in:5.2%, P = 0.039). There was also less time <54 mg/dL (CLC: 0.7%, run-in:1.6%, P = 0.030) and >180 mg/dL (CLC: 4.9%, run-in: 13.1%, P = 0.032). Overnight glucose control was comparable, except for less time >250 mg/dL (CLC: 0%, run-in:3.9%, P = 0.030) and lower glucose standard deviation (CLC: 23.8 mg/dL, run-in:42.8 mg/dL, P = 0.007) during CLC. Conclusion: In this pilot study, use of the pregnancy-specific zone-MPC was feasible in pregnant women with T1D. Although the duration of our study was short and the number of participants was small, our findings add to the limited data available on the use of CLC systems during pregnancy (NCT04492566).

Combination Use of U-500 Regular Insulin via Insulin Pump and Rapid-Acting U-100 Prandial Injections for Treatment of Pre-Existing Type 2 Diabetes in Pregnancy

The high-dose large-volume insulin injections that may become necessary during pregnancy due to marked pregnancy-induced insulin resistance may result in suboptimal therapeutic effectiveness. Use of U-500 insulin, a concentrated insulin formulation, has been suggested during pregnancy. However, the pharmacokinetic properties of U-500 insulin monotherapy can impede achievement of strict pregnancy glycemic targets. We propose a novel regimen for treatment of severe pregnancy-induced insulin resistance that enables precise delivery of U-500 basal insulin therapy through continuous subcutaneous insulin infusion (CSII) while maintaining the desired kinetics of prandial rapid-acting U-100 insulin therapy. This combination approach, guided by continuous glucose monitoring data, enabled achievement of pregnancy glycemic targets while reducing basal insulin requirements by approximately one-third. We report our method for (1) conversion to U-500 insulin delivery through CSII during pregnancy and (2) conversion from U-500 basal insulin delivery through CSII to U-100 intravenous insulin infusion therapy at delivery, to offer clinicians who encounter similar challenging scenarios a novel approach to diabetes management during pregnancy in the setting of marked insulin resistance.

Pregnant women's experience of undergoing an oral glucose tolerance test: A cross-sectional study

AIMS

The oral glucose tolerance test (OGTT) is routinely performed in most pregnancies; however, there are few studies which document the experience of taking this test. We assessed the experience of pregnant women during an OGTT.

METHODS

This cross-sectional study included 152 women (24-32 weeks' gestation) and assessed their knowledge, anxiety (Spielberg anxiety inventory test-STAI), and physical pain (0-10 visual analog scale) during the OGTT. The Friedman test was used to compare pain scores over time.

RESULTS

61 (40%) participants did not know why they were doing the OGTT and 73 (48%) women had high state-anxiety levels (STAI ≥ 41 points, 20-80 scale). Participants had mild to moderate pain scores immediately after the first and second blood draws (3.9 ± 2.7 and 3.8 ± 2.3, respectively) that decreased significantly after the third blood draw (2.8 ± 2.4, P < 0.001). Nearly half (n = 71, 47%) of the participants were very or extremely bothered with having to drink the glucose solution.

CONCLUSIONS

The OGTT was associated with high levels of anxiety and mild to moderate physical pain. Ingestion of the glucose solution was perceived as the most difficult part of the test. Good strategies can help to mitigate some of these negative experiences while undergoing an OGTT.

A Review of National Level Guidelines for Risk Management of Cardiovascular and Diabetic Disease

Cardiovascular diseases and diabetes are among the leading preventable causes of morbidity and mortality. Cardiovascular disease risk reduction aimed to address the significant modifiable risk factors, including lifestyle-related risk factors, hypertension, hyperlipidemia, and diabetes. Given the severity and disease burden, many insurances, including Medicare, cover the annual counseling for risk reduction of cardiovascular disease. Although numerous national-level guidelines are available for managing these conditions, most of them focus on disease management. Given the broad areas covered in these recommendations, a concise review summarizing the measures addressing the preventive approach in these conditions is not readily available. Herewith, we review and outline the currently available guidelines from national-level publications with principal attention to the primary prevention measures to provide a broad overview and assist providers with the risk reduction counseling.

Uptake of guideline-recommended postpartum diabetes screening among diverse women with gestational diabetes: associations with patient factors in an integrated health system in USA

INTRODUCTION

Clinical guidelines urge timely postpartum screening for diabetes among women with gestational diabetes mellitus (GDM), yet patient factors associated with screening uptake remain unclear. We aimed to identify patient factors associated with completed postpartum diabetes screening (2-hour oral glucose tolerance test within 4-12 weeks postpartum), as recommended by the American Diabetes Association (ADA).

RESEARCH DESIGN AND METHODS

Within the context of Gestational Diabetes' Effects on Moms (GEM), a pragmatic cluster randomized trial (2011-2012), we examined survey and electronic health record data to assess clinical and sociodemographic factors associated with uptake of ADA-recommended postpartum screening. Participants included 1642 women (76% racial/ethnic minorities) identified with GDM according to the Carpenter and Coustan criteria in a health system that deploys population-level strategies to promote screening. To contextualize these analyses, screening rates derived from the GEM trial were compared with those in the health system overall using registry data from a concurrent 10-year period (2007-2016, n=21 974).

RESULTS

Overall 52% (n=857) completed recommended postpartum screening in the analytic sample, comparable to 45.7% (n=10 040) in the registry. Screening in the analytic sample was less likely among women at elevated risk for type 2 diabetes, assessed using items from an ADA risk test (vs non-elevated; adjusted rate ratio (aRR)=0.86 (95% CI 0.75 to 0.98)); perinatal depression (0.88 (0.79 to 0.98)); preterm delivery (0.84 (0.72 to 0.98)); parity ≥2 children (vs 0; 0.80 (0.69 to 0.93)); or less than college education (0.79 (0.72 to 0.86)). Screening was more likely among Chinese Americans (vs White; 1.31 (1.15 to 1.49)); women who attended a routine postpartum visit (5.28 (2.99 to 9.32)); or women who recalled receiving healthcare provider advice about screening (1.31 (1.03 to 1.67)).

CONCLUSIONS

Guideline-recommended postpartum diabetes screening varied by patient clinical and sociodemographic factors. Findings have implications for developing future strategies to improve postpartum care.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

Vitamin D Status and Gestational Diabetes in Russian Pregnant Women in the Period between 2012 and 2021: A Nested Case-Control Study

Several meta-analyses found an association between low maternal serum 25-hydroxyvitamin D (25(OH)D) level and gestational diabetes mellitus (GDM). However, some of them reported significant heterogeneity. We examined the association of serum 25(OH)D concentration measured in the first and in the second halves of pregnancy with the development of GDM in Russian women surveyed in the periods of 2012−2014 and 2018−2021. We conducted a case−control study (including 318 pregnant women) nested on two previous studies. In 2012−2014, a total of 214 women (83 GDM and 131 controls) were enrolled before 15 weeks of gestation and maternal serum 25(OH)D concentrations were measured twice: at 8th−14th week of gestation and simultaneously with two-hour 75 g oral glucose tolerance test (OGTT) at 24th−32nd week of gestation. In the period of 2018−2021, 104 women (56 GDM and 48 controls) were included after OGTT and 25(OH)D concentrations were measured at 24th−32nd week of gestation. Median 25(OH)D levels were 20.0 [15.1−25.7] vs. 20.5 [14.5−27.5] ng/mL (p = 0.565) in GDM and control group in the first half of pregnancy and 25.3 [19.8−33.0] vs. 26.7 [20.8−36.8] ng/mL (p = 0.471) in the second half of pregnancy, respectively. The prevalence rates for vitamin D deficiency (25(OH)D levels < 20 ng/mL) were 49.4% and 45.8% (p = 0.608) in the first half of pregnancy and 26.2% vs. 22.1% (p = 0.516) in the second half of pregnancy in women who developed GDM and in women without GDM, respectively. The frequency of vitamin D supplements intake during pregnancy increased in 2018−2021 compared to 2012−2014 (p = 0.001). However, the third trimester 25(OH)D levels and prevalence of vitamin D deficiency (25.5 vs. 23.1, p = 0.744) did not differ in women examined in the periods of 2012−2014 and 2018−2021. To conclude, there was no association between gestational diabetes risk and maternal 25(OH)D measured both in the first and in the second halves of pregnancy. The increased prevalence of vitamin D supplements intake during pregnancy by 2018−2021 did not lead to higher levels of 25(OH)D.

Exercise and Self-Management in Adults with Type 1 Diabetes

PURPOSE OF REVIEW

The purpose of this review paper is to examine the most recent evidence of exercise-related self-management in adults with type 1 diabetes (T1D).

RECENT FINDINGS

This paper reviews the benefits and barriers to exercise, diabetes self-management education, the role of the healthcare provider in assessment and counseling, the use of technology, and concerns for special populations with T1D. Adults with T1D may not exercise at sufficient levels. Assessing current levels of exercise, counseling during a clinical visit, and the use of technology may improve exercise in this population.

Time in range measurements for hyperglycemia management during pregnancy

The prevalence of adverse pregnancy outcomes associated with poor glycemic control are increasing. Accordingly, effective blood glucose monitoring during pregnancy has become a subject of intense interest. Continuous glucose monitoring (CGM) displays dynamic changes in blood glucose by using probes to measure glucose concentration in the interstitial fluid, and the rapid development of CGM has enabled the investigation of time in range (TIR) in the glucose target range as a new parameter to evaluate blood glucose. International guidelines have identified TIR as an important blood glucose assessment method for pregnant patients with type 1 diabetes mellitus that overcomes the limitations of conventional gestational blood glucose monitoring, better reflects fluctuation in blood glucose during pregnancy, and effectively improves maternal and neonatal outcomes. However, there is little clinical evidence for the use of TIR in pregnant women with gestational diabetes mellitus and those with pre-pregnant type 2 diabetes mellitus. TIR is expected to become a critical indicator of blood glucose control and management in hyperglycemic pregnant patients. We review the research progress of TIR to help clinicians understand the field of blood glucose monitoring in pregnant women with hyperglycemia.

Equity in Psychosocial Outcomes and Care for Racial and Ethnic Minorities and Socioeconomically Disadvantaged People With Diabetes

The role of social determinants of health (SDOH) in promoting equity in diabetes prevalence, incidence, and outcomes continues to be documented in the literature. Less attention has focused on disparities in psychosocial aspects of living with diabetes and the role of SDOH in promoting equity in psychosocial outcomes and care. In this review, the authors describe racial/ethnic and socioeconomic disparities in psychosocial aspects of living with diabetes, discuss promising approaches to promote equity in psychosocial care, and provide future research directions.

Impact of Risk Factors on Short and Long-Term Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: A Prospective Longitudinal Cohort Study

AIMS

Universal screening of gestational diabetes mellitus (GDM) in women with no risk factors (RF) for GDM remains controversial. This study identified the impact of the presence of RF on perinatal and postpartum outcomes.

METHODS

This prospective cohort study included 780 women with GDM. GDM RF included previous GDM, first grade family history of type 2 diabetes, high-risk ethnicity and pre-pregnancy overweight/obesity (OW/OB). Outcomes included obstetrical, neonatal and maternal metabolic parameters during pregnancy and up to 1 year postpartum.

RESULTS

Out of 780 patients, 24% had no RF for GDM. Despite this, 40% of them needed medical treatment and they had a high prevalence of glucose intolerance of 21 and 27% at 6-8 weeks and 1-year postpartum, respectively. Despite similar treatment, women with RF had more neonatal and obstetrical complications, but they had especially more frequent adverse metabolic outcomes in the short- and long-term. The most important RF for poor perinatal outcome were previous GDM and pre-pregnancy OW/OB, whereas high-risk ethnicity and pre-pregnancy OW/OB were RF for adverse postpartum metabolic outcomes. Increasing number of RF were associated with worsened perinatal and long-term postpartum outcomes except for pregnancy-induced hypertension, C-section delivery and neonatal hypoglycaemia.

CONCLUSION

Women with no RF had a high prevalence of adverse perinatal and postpartum outcomes, while the presence of RF particularly increased the risk for postpartum adverse metabolic outcomes. This calls for a RF-based long-term follow-up of women with GDM.

It Takes a Brain, a Heart, Courage, and Support

Editor's note: This article is adapted from the virtual address Dr. Charron-Prochownik delivered as the recipient of the American Diabetes Association's Outstanding Educator in Diabetes Award for 2021. She delivered the address in June 2021 during the Association's 81st Scientific Sessions, which was held online as a result of the coronavirus disease 2019 pandemic. A webcast of this speech is available for viewing on the DiabetesPro website (https://bit.ly/3Lry4B9).