Use of Insulin Lispro Protamine Suspension in Pregnancy

A meta-analysis of metformin and insulin on maternal outcome and neonatal outcome in patients with gestational diabetes mellitus

INTRODUCTION

The use of metformin for treating gestational diabetes mellitus (GDM) remains controversial because it can pass through the placenta. This meta-analysis aimed to compare the effects of metformin and insulin on maternal and neonatal outcomes in patients with GDM.

METHODS

We conducted a comprehensive search of the PubMed, Embase, and Cochrane Library databases, focusing on randomized controlled trials (RCTs) that evaluated the impacts of metformin and insulin on both maternal and neonatal outcomes in patients with GDM.

RESULTS

Twenty-four RCTs involving 4934 patients with GDM were included in this meta-analysis. Compared with insulin, metformin demonstrated a significant reduction in the risks of preeclampsia (RR 0.61, 95% CI 0.48 to 0.78, p < .0001), induction of labor (RR 0.90, 95% CI 0.82 to 0.98, p = .02), cesarean delivery (RR 0.91, 95% CI 0.85 to 0.98, p = .01), macrosomia (RR 0.67, 95% CI 0.53 to 0.83, p = .0004), neonatal intensive care unit (NICU) admission (RR 0.75, 95% CI 0.66 to 0.86, p < .0001), neonatal hypoglycemia (RR 0.55, 95% CI 0.48 to 0.63, p < .00001), and large for gestational age (LGA) (RR 0.80, 95% CI 0.68 to 0.94, p = .007). Conversely, metformin showed no significant impact on gestational hypertension (RR 0.84, 95% CI 0.67 to 1.06, p = .15), spontaneous vaginal delivery (RR 1.13, 95% CI 1.00 to 1.08, p = .05), emergency cesarean section (RR 0.94, 95% CI 0.77 to 1.16, p = .58), shoulder dystocia (RR 0.65, 95% CI 0.31 to 1.39, p = .27), premature birth (RR 0. 92, 95% CI 0.61 to 1.39, p = .69), polyhydramnios (RR 1.11, 95% CI 0.54 to 2.30, p = .77), birth trauma (RR 0.87, 95% CI 0.54 to 1.39, p = .56), 5-min Apgar score < 7 (RR 1.13, 95% CI 0.76 to 1.68, p = .55), small for gestational age (SGA) (RR 0.93, 95% CI 0.71 to 1.22, p = .62), respiratory distress syndrome (RDS) (RR 0.74, 95% CI 0.50 to 1.08, p = .11), jaundice (RR 1.09, 95% CI 0.95 to 1.25, p = .24) or birth defects (RR 0.80, 95% CI 0.37 to 1.74, p = .57).

CONCLUSIONS

The findings suggest that metformin can reduce the risk of certain maternal and neonatal outcomes compared with insulin therapy for GDM. However, long-term follow-up studies of patients with GDM taking metformin and their offspring are warranted to provide further evidence.

Insulin Therapy and Diabetic Pregnancy

BACKGROUND

A good metabolic control before conception and throughout pregnancy with diabetes decreases the risk of short- and long-term adverse outcomes of the mothers and their offsprings. Insulin treatment remains the gold standard treatment recommended for any type of diabetes. New technologies including new insulins and insulin analogues, continuous subcutaneous insulin infusion without and with sensors, the low-glucose predictive suspension function, and closed-loop systems that persistently and automatically self-adjust according to patients' continuous glucose monitoring readings have expanded the offer to clinicians for achieving tight glucose control.

AREAS OF UNCERTAINTY

Unsafe effects of insulin and insulin analogues in pregnancy with diabetes could be linked with changes in insulin immunogenicity, teratogenicity, and mitogenicity. Second-generation insulin analogues need to be tested and proven. Effectiveness and safety of new insulin delivery systems in real life of diabetic women in pregnancy need further confirmations.

SOURCES

MEDLINE, EMBASE, Web of Science, Cochrane Library, randomized controlled trials, systematic review and meta-analysis, observational prospective and retrospective studies, case series reports for the most recent insulin analogues, published in English impacted journals, and consensus statements from scientific societies I excluded 60 from 221 papers as not suitable for the purpose of the subject.

RESULTS

Subcutaneous insulin infusion can be safely used during pregnancy and delivery of well-trained women. Sensors are increasingly accurate tools that improve the efficacy and safety of integrated systems' functioning. Continuous glucose monitoring provides metrics ("time in range" time in "hypoglycemia" and in "hyperglycemia," glucose variability, average glucose levels in different time intervals) used as a guide to diabetes management; these new metrics are object of discussion in special populations. Randomized controlled trials have shown that sensor-augmented pump therapy improves pregnancy outcomes in women with type 1 diabetes. Closed-loop insulin delivery provides better glycemic control than sensor-augmented pump therapy during pregnancy, before, and after delivery.

CONCLUSION

Second-generation insulin analogues and newer insulin infusion systems that automatically self-adjust according to patients continuous glucose monitor readings are important tools improving the treatment and quality of life of these women. Multi-institutional and disciplinary teams are working to develop and evaluate a pregnancy-specific artificial pancreas.

Pregnancy Outcomes in Women with Strictly Controlled Type 1 Diabetes Mellitus

OBJECTIVE

To evaluate the pregnancy outcomes in mothers with controlled Type 1 diabetes mellitus (T1DM).

MATERIALS AND METHODS

Thirty seven pregnant patients with controlled T1DM were included in the study.

RESULTS

Twenty (54%) out of 37 patients had preterm delivery (<37 weeks of gestation). The type of delivery was induced vaginal delivery in 9 (24.3%) patients and cesarean section in 27 (72.9%) patients. Preeclampsia developed in 6 (16.2%) patients. Macrosomia was found in 9 (24%) patients. Two antenatal death occured.

CONCLUSION

Even in the most favorable conditions, the pregnant patients with T1DM would have a great risk for preterm delivery and cesarean section, moderate risk for macrosomia, preeclampsia, and an undefined risk for antenatal death.