Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes

Diabetes and pregnancy study (DAPSY): a 10-year single-center cohort study of pregnancies affected by diabetes

PURPOSE

The aim of our study was to investigate to what degree clinical characteristics can contribute to incidence and structure of pregnancy and childbirth complications in women with diabetes, and to reveal key risk factors for adverse outcomes.

METHODS

We conducted a retrospective single-center cohort study from January 2008 through December 2017, including 3069 singleton pregnancies, affected by type 1 diabetes (T1D, n = 498), type 2 diabetes (T2D, n = 214), and gestational diabetes mellitus (GDM, n = 2357).

RESULTS

More than 10 years duration of T1D associated with increased risk for preterm birth (RR 2.03, 95% CI 1.28-3.20) and preeclampsia (RR 1.57, 95% CI 1.09-2.26). Diabetic nephropathy, same as diabetic proliferative retinopathy, was associated with increased risk of C-section, preeclampsia development, SGA delivery. In patients with T1D who received CSII (12%), we do not report superior outcomes compared to MDI. Pre-pregnancy HbA1c level less than 6.5% reduced the risk of preeclampsia for T1D (RR 0.28, 95% CI 0.19-0.67) and risk of LGA birth for T2D (RR 0.43, 95% CI 0.19-0.92). Achieving glycemic target values by full-term pregnancy reduced the risk of excessive fetal adiposity (RR 0.81 for T1D, RR 0.39 for T2D). For T2D and GDM, the leading risk factors were obesity and chronic hypertension. For patients with GDM, insulin administration and early diagnosis of GDM were the significant risk factors for adverse outcomes.

CONCLUSION

Diabetes during pregnancy is challenging for the clinician, but optimizing glycemic control, treatment regimens, and close attention to comorbidities can help to reduce the risks and ensure appropriate quality diabetes management.

Knowledge of Gestational Diabetes Mellitus Among Saudi Women in a Primary Health Care Center of Almadinah Almunawarah, Kingdom of Saudi Arabia

Background

Gestational diabetes mellitus (GDM) is a type of diabetes mellitus known as any stage of glucose intolerance with onset or first recognition during pregnancy. Awareness of GDM is the first step toward its screening in pregnancy. This study was designed to assess knowledge of GDM, its screening, and risk factors among Saudi women attending primary healthcare center in Almadinah Almunawarah, Kingdom of Saudi Arabia.

Methods

This was an observational cross-sectional study conducted on Saudi women who attended the primary healthcare centers in Almadinah Almunawarah during the study period from January 2021 to June 2021. The sampling technique used was the stratification of primary healthcare centers in Madinah. According to the Epi-Info, version 3.5.1, the minimum sample size was 292. Data collection was done using a valid, Arabic self-administered questionnaire, which was composed of two main parts: general sociodemographic data and a questionnaire to assess GDM knowledge and awareness (12 questions). Data was recorded and analyzed using SPSS version 26.

Results

In this study, 333 women were enrolled with an age range between 18 and 60 years, with a mean of 34.31±9.21 years. Overall, more than half of the women (53.45%) had a poor level of knowledge related to GDM, whereas only 7.80% had a good level of knowledge. Results of multivariate logistic regression analysis revealed that women living in rural areas were at almost four-fold higher risk of having a poor level of knowledge (adjusted odds ratio (aOR): 3.97; 95% confidence interval (CI): 1.44-41.98, p=0.0031). With a one-year increase in women’s age, the risk of poor knowledge increased by 4% (aOR: 1.38; 95% CI: 1.08-1.48, p=0.001). In comparison to illiterate women, university-graduated and postgraduate women had a significantly lower risk of poor knowledge (aOR: 0.03; 95% CI: 0.01-0.31, p=0.001 and aOR: 0.19; 95% CI: 0.06-0.66, p = 0.011, respectively).

Conclusion

The GDM knowledge of Saudi adult women was poor, particularly regarding risk factors, diagnosis, and treatment with insulin. However, their knowledge regarding treatment by lifestyle and diet modifications was quite acceptable.

Quality appraisal of systematic reviews on methods of labour induction: a systematic review

PURPOSE

Induction of labour has become more common over the last decade, together with an increase in the number of systematic reviews of the subject. However, with multiple systematic reviews it is necessary to evaluate the methodological rigor to ensure the reliability of conclusions and recommendations for clinical practice. Therefore, the aim of this study was to appraise the quality of systematic reviews that examined the efficacy and/or safety of labour induction methods.

METHODS

An electronic search of MEDLINE, Embase, and the Cochrane Library from 2000 to 2020 was conducted. Study selection, data extraction and quality assessment were conducted using A Measurement Tool to Assess Systematic Reviews (AMSTAR) by two independent reviewers, in duplicate.

RESULTS

The search identified 387 publications, of which 48 studies (13%) met the a priori inclusion criteria. No significant relationships were found between study quality and number of citations, journal impact factor, or publication year.

CONCLUSION

Methodological quality for systematic reviews on the induction of labour were ranked as moderate with no significant changes in quality over the past 2 decades. Publication characteristics are not significantly associated with methodological quality, indicating that healthcare professionals should critically appraise studies before applying them to practice.

Correlates of blood pressure and blood glucose screenings in Cameroon: insights from the 2018 Demographic and Health Survey

Background

Hypertension and diabetes, two major risk factors for cardiometabolic diseases, are associated with high morbidity and mortality rates. Early detection through screening can initiate early treatment to reduce adverse outcomes. The current study sought to investigate the correlates of blood pressure and blood glucose screenings in Cameroon.

Methods

We used secondary data from the 2018 Cameroon Demographic and Health Survey. Adjusting for a complex sample design, we performed multivariate prevalence ratio estimates of the blood pressure and blood glucose screenings.

Results

Approximately 60% and 30% of Cameroonians had undergone blood pressure and blood glucose screenings, respectively. More females (68%) had undergone blood pressure screenings compared with their male counterparts (44.1%). In the multivariate model, gender, age, education, marital status, household wealth index and region of residence were significantly associated with both blood pressure and blood glucose screenings in the full sample. Previous blood pressure screening was associated with an increased likelihood of blood glucose screening and vice versa. A modification effect of gender was observed in the association between the correlates and both outcomes.

Conclusion

Our findings uncovered individuals with a decreased likelihood for blood pressure and blood glucose screenings and this can inform policy decisions to ensure targeted screening aimed at early detection and management.

Intracervical double-balloon catheter versus dinoprostone for cervical ripening in labor induction in pregnancies with a high risk of uterine hyperstimulation

PURPOSE

There are numerous methods for cervical ripening although not all of them are indicated in women presenting a higher risk of uterine hyperstimulation. To compare the efficacy and security of the two methods for cervical ripening in the induction of labor in these pregnancies.

METHODS

Retrospective analysis of two cohorts consisting of pregnant women who gave birth from 2016 to 2019 (112 inductions with dinoprostone and 112 with intracervical double- balloon).

RESULTS

There are statistically significant differences in favor of dinoprostone in deliveries that occurred before 12 h since the start of the induction (28.6% vs 13.4%, p = 0.005) and a higher rate of cervical ripening (55.4% vs 33.9%; p = 0.001). There were no statistically significant differences in induction time, the percentage of women delivering within 24 h or beyond, nor in the type of delivery. Additionally, a decreased need of oxytocin (60.7% vs 42.9%; p = 0.001) and a lower dose when used has been observed in the dinoprostone group. However, Dinoprostone also has a higher rate of minor maternal complications as uterine hyperstimulation (18.8% vs 3.6%; p = 0.001) and altered cardiotocography (26.8% vs 4.5%; p = 0.001). No significant difference has been found between the two groups regarding severe complications.

CONCLUSIONS

Dinoprostone presents a greater efficacy for cervical ripening and delivery in ≤ 12 h, with less need of oxytocin perfusion than inductions using an intracervical double-balloon. There is no significant difference in severe maternal complications between the two groups. In conclusion, Dinoprostone could be an effective and safe option for patients at risk of uterine hyperstimulation.

Time trends in pregnancy-related outcomes among women with type 1 diabetes mellitus, 2004-2017

OBJECTIVE

To examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes.

STUDY DESIGN

We abstracted clinical data from the medical records of 700 pregnant women from 2004 to 2017. For each time period, means and percentages were calculated. P values for trend were calculated using linear and logistic regression.

RESULTS

HbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (P = 0.002). Excessive gestational weight gain increased (P = 0.01). Gestation length also increased (P = 0.01), as did vaginal deliveries (P = 0.03). There were no change in birthweight over time (P = 0.07) and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged.

CONCLUSION

Obstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA.

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.

Drugs to Control Diabetes During Pregnancy

Diabetes is a common complication of pregnancy associated with both short- and long-term adverse maternal and offspring effects. All types of diabetes in pregnancy are increasing in prevalence. Treatment of diabetes in pregnancy, targeting glycemic control, improves both maternal and offspring outcomes, albeit imperfectly for many women. Pharmacologic treatment recommendations differ between pregestational and gestational diabetes. Improved treatment of diabetes in pregnancy will need to consider maternal disease heterogeneity and comorbidities as well as long-term offspring outcomes. In this review, the authors summarize recent clinical studies to highlight established pharmacologic treatments for diabetes in pregnancy and provide suggestions for further research.

Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes

BACKGROUND

There are a number of ways of monitoring blood glucose in women with diabetes during pregnancy, with self-monitoring of blood glucose (SMBG) recommended as a key component of the management plan. No existing systematic reviews consider the benefits/effectiveness of different techniques of blood glucose monitoring on maternal and infant outcomes among pregnant women with pre-existing diabetes. The effectiveness of the various monitoring techniques is unclear. This review is an update of a review that was first published in 2014 and subsequently updated in 2017.

OBJECTIVES

To compare techniques of blood glucose monitoring and their impact on maternal and infant outcomes among pregnant women with pre-existing diabetes.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM), automated telemedicine monitoring or clinic monitoring among pregnant women with pre-existing diabetes mellitus (type 1 or type 2). Trials investigating timing and frequency of monitoring were also eligible for inclusion. RCTs using a cluster-randomised design were eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This review update includes a total of 12 trials (863) women (792 women with type 1 diabetes and 152 women with type 2 diabetes). The trials took place in Europe, the USA and Canada. Three of the 12 included studies are at low risk of bias, eight studies are at moderate risk of bias, and one study is at high risk of bias. Four trials reported that they were provided with the continuous glucose monitors free of charge or at a reduced cost by the manufacturer.Continuous glucose monitoring (CGM) versus intermittent glucose monitoring, (four studies, 609 women)CGM may reduce hypertensive disorders of pregnancy (pre-eclampsia and pregnancy-induced hypertension) (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.85; 2 studies, 384 women; low-quality evidence), although it should be noted that only two of the four relevant studies reported data for this composite outcome. Conversely, this did not translate into a clear reduction for pre-eclampsia (RR 0.65, 95% CI 0.39 to 1.08; 4 studies, 609 women, moderate-quality evidence). There was also no clear reduction in caesarean section (average RR 0.94, 95% CI 0.75 to 1.18; 3 studies, 427 women; I2 = 41%; moderate-quality evidence) or large-for-gestational age (average RR 0.84, 95% CI 0.57 to 1.26; 3 studies, 421 women; I2 = 70%; low-quality evidence) with CGM. There was not enough evidence to assess perinatal mortality (RR 0.82, 95% CI 0.05 to 12.61, 71 infants, 1 study; low-quality evidence), or mortality or morbidity composite (RR 0.80, 95% CI 0.61 to 1.06; 1 study, 200 women) as the evidence was based on single studies of low quality. CGM appears to reduce neonatal hypoglycaemia (RR 0.66, 95% CI 0.48 to 0.93; 3 studies, 428 infants). Neurosensory disability was not reported.Other methods of glucose monitoringFor the following five comparisons, self-monitoring versus a different type of self-monitoring (two studies, 43 women); self-monitoring at home versus hospitalisation (one study, 100 women), pre-prandial versus post-prandial glucose monitoring (one study, 61 women), automated telemedicine monitoring versus conventional system (three studies, 84 women), and constant CGM versus intermittent CGM (one study, 25 women), it is uncertain whether any of the interventions has any impact on any of our GRADE outcomes (hypertensive disorders of pregnancy, caesarean section, large-for-gestational age) because the quality of the evidence was found to be very low. This was due to evidence largely being derived from single trials, with design limitations and limitations with imprecision (wide CIs, small sample sizes, and few events). There was not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Other important outcomes, such as neurosensory disability, were not reported in any of these comparisons.

AUTHORS' CONCLUSIONS

Two new studies (406 women) have been incorporated to one of the comparisons for this update. Although the evidence suggests that CGM in comparison to intermittent glucose monitoring may reduce hypertensive disorders of pregnancy, this did not translate into a clear reduction for pre-eclampsia, and so this result should be viewed with caution. No differences were observed for other primary outcomes for this comparison. The evidence base for the effectiveness of other monitoring techniques analysed in the other five comparisons is weak and based on mainly single studies with very low-quality evidence. Additional evidence from large well-designed randomised trials is required to inform choices of other glucose monitoring techniques and to confirm the effectiveness of CGM.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews

BACKGROUND

Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB.

OBJECTIVES

We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update.

METHODS

We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI.

MAIN RESULTS

We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB.

OUTCOME

preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions.

OUTCOME

perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources.

OUTCOMES

preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm.

AUTHORS' CONCLUSIONS

Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

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.

Controversies and Advances in Gestational Diabetes-An Update in the Era of Continuous Glucose Monitoring

Diabetes in pregnancy, both preexisting type 1 or type 2 and gestational diabetes, is a highly prevalent condition, which has a great impact on maternal and fetal health, with short and long-term implications. Gestational Diabetes Mellitus (GDM) is a condition triggered by metabolic adaptation, which occurs during the second half of pregnancy. There is still a lot of controversy about GDM, from classification and diagnosis to treatment. Recently, there have been some advances in the field as well as recommendations from international societies, such as how to distinguish previous diabetes, even if first recognized during pregnancy, and newer diagnostic criteria, based on pregnancy outcomes, instead of maternal risk of future diabetes. These new recommendations will lead to a higher prevalence of GDM, and important issues are yet to be resolved, such as the cost-utility of this increase in diagnoses as well as the determinants for poor outcomes. The aim of this review is to discuss the advances in diagnosis and classification of GDM, as well as their implications in the field, the issue of hyperglycemia in early pregnancy and the role of hemoglobin A1c (HbA1c) during pregnancy. We have looked into the determinants of the poor outcomes predicted by the diagnosis by way of oral glucose tolerance tests, highlighting the relevance of continuous glucose monitoring tools, as well as other possible pathogenetic factors related to poor pregnancy outcomes.