Medical complications of diabetes mellitus in pregnancy

Performance of the Dexcom G6 Continuous Glucose Monitoring System in Pregnant Women with Diabetes

Background: The aim of this study was to determine the performance of the Dexcom G6 continuous glucose monitoring (CGM) system across three sensor wear sites in pregnant women with diabetes in the second or third trimesters. Methods: Participants with type 1 (T1D), type 2 (T2D), or gestational (GDM) diabetes mellitus were enrolled at three sites. Each wore two G6 sensors on the abdomen, upper buttock, and/or posterior upper arm for 10 days and underwent a 6-h clinic session between days 3 and 7 of sensor wear, during which YSI reference blood glucose values were obtained every 30 min. No intentional glucose manipulations were performed. Accuracy metrics included the proportion of CGM values that were within ±20% of paired reference values >100 mg/dL or ±20 mg/dL of YSI values ≤100 mg/dL (hereafter referred to as %20/20), as well as the analogous %15/15, %30/30, and %40/40. The mean absolute relative difference (MARD) between CGM-YSI pairs was also calculated. Results: Thirty-two participants with T1D (n = 20), T2D (n = 3), or GDM (n = 9) were enrolled: 19 were in the second trimester and 13 were in the third trimester of pregnancy. Compared with the reference, 92.5% of CGM values were within ±20%/20 mg/dL. The overall MARD and that of sensors worn on the abdomen, upper buttock, and posterior upper arm was 10.3%, 11.5%, 11.2%, and 8.7%, respectively. There were no device-related adverse events. Skin reactions at the insertion sites were absent or minor. Conclusions: The Dexcom G6 CGM system is accurate and safe in pregnant women with diabetes.

Alterations of carbohydrate metabolism during pregnancy. Effects on the mother and new born infant

INTRODUCTION

Gestational diabetes is the pathology that most frequently causes medical alterations in pregnancy. The objective of this study was to assess the relationship between the presence of alterations in the metabolism of carbohydrates during pregnancy and the risk of adverse obstetric outcomes in mother and foetus.

PATIENTS AND METHOD

An observational study was conducted on 799 women who had just given birth. The clinical and obstetric characteristics of the patients, as well as the data related to pregnancy and delivery, including the state of the new born infant were analysed. The information was evaluated in relation to the alterations in carbohydrate metabolism.

RESULTS AND DISCUSSION

For women with gestational diabetes a 2.64 times greater risk of loss of foetal well-being and 3.14 times greater risk of requiring hospitalization during pregnancy were found. For pregnant women with carbohydrate intolerance, a 2.61 times higher risk of requiring episiotomy in vaginal delivery, a 7.54 times greater risk of finding loss of foetal well-being, and a 2.06 times greater risk of requiring hospitalization were found. The group with carbohydrate intolerance behaved similarly to that with diabetes.

CONCLUSIONS

The group with intolerance to carbohydrates is a little studied group and significant obstetric alterations were found compared to the control group and similar to those of the gestational diabetes group.

Factors determining insulin requirements in women with type 1 diabetes mellitus during pregnancy: a review

Most women with type 1 diabetes mellitus (T1DM) have increased insulin requirements during pregnancy. However, a minority of women have a fall in insulin requirements. When this occurs in late gestation, it often provokes concern regarding possible compromise of the feto-placental unit. In some centres, this is considered as an indication for delivery, including premature delivery. There are, however, many other factors that affect insulin requirements in pregnancy in women with type 1 diabetes mellitus and the decline in insulin requirements may represent a variant of normal pregnancy. If there is no underlying pathological process, expedited delivery in these women is not warranted and confers increased risks to the newborn. We will explore the factors affecting insulin requirements in gestation in this review. We will also discuss some novel concepts regarding beta-cell function in pregnancy.

Insulin requirements in late pregnancy in women with type 1 diabetes mellitus: a retrospective review

Pregnancy in women with type 1 diabetes mellitus (T1DM) is generally associated with increased insulin requirements.

AIMS

To determine the frequency and significance of declining insulin requirements in late gestation in women with T1DM.

METHODS

We conducted a retrospective review of 54 women seen at our institution from 2006 to 2010 with a diagnosis of T1DM pre-pregnancy and presentation for antenatal care prior to 28 weeks. Information was collected regarding patient demographics, insulin dose and pregnancy outcome. A 15% difference in weight-adjusted basal insulin from 30 weeks gestation to delivery was considered significant.

RESULTS

Five women (9.3%) had a fall of 15% or more and 23 (42.5%) had a rise of 15% or more rise in insulin requirements. There were fewer neonatal intensive care admissions but more infants with an APGAR <8 at 5 min in women with a fall in insulin requirements. These differences were not evident when the data were re-analysed by quartiles of change.

CONCLUSIONS

In most women with T1DM, insulin requirements show little change from 30 weeks gestation until delivery. Almost 10% of women had a significant fall in insulin requirements which did not correlate with adverse neonatal outcome. These results require validation in a larger, prospective trial.

Effects of pregnancy on the onset and progression of diabetic nephropathy and of diabetic nephropathy on pregnancy outcomes

Controversy exists regarding the effect of pregnancy on the development and course of diabetic nephropathy. This study followed 43 pregnant women with previous diabetes mellitus, 32 without nephropathy (Group I) and 11 with nephropathy (Group II). Urinary albumin excretion (UAE), serum creatinine (Cr) and creatinine clearance (CCr) in the pre-pregnancy (Pre-P), first trimester (1T), third trimester (3T) and 1 year postpartum (PP) were evaluated. In both groups there were an increase in 3T compared to Pre-P of CCr (137 vs. 98 ml/min and 110 vs. 81 ml/min, p=0.0001, respectively) and UAE (7.78 vs. 3.15 mg/24 h and 592 vs. 119 mg/24 h, p=0.0001, respectively). Increase of Cr in the PP compared to 1T in Group II (0.88 vs. 0.70 mg/dL, p=0.031) was observed. There were no difference in UAE, CCr and Cr in the PP when compared to pre-P as well variance over time between groups. Group II showed higher prevalence of chronic hypertension (72.7 vs. 21.9%, p=0.004), preeclampsia (63.6 vs. 6.3%, p=0.0003) and lower gestational age at birth (36 vs. 38 weeks, p=0.003). We conclude that pregnancy was not associated with development and progression of diabetic nephropathy in women with or without mild renal dysfunction. The presence of diabetic nephropathy was associated with increased risk of perinatal complications.

Pregestational diabetes

The prevalence of preexisting diabetes in pregnancy is increasing largely because of an increase in type 2 diabetes. Outcomes of diabetic pregnancies for mother and newborn have improved greatly in recent decades from advances in understanding the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and pregnancy-associated insulin resistance can make glycemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and peripartum periods.

Are adverse pregnancy outcomes risk factors for development of end-stage renal disease in women with diabetes?

BACKGROUND

It is unknown whether adverse pregnancy-related outcomes in women with pregestational diabetes are associated with later development of end-stage renal disease (ESRD) or death.

METHODS

We linked data from the Medical Birth Registry of Norway with data from the Norwegian Renal Registry and the Norwegian Cause of Death Registry. Data from up to three pregnancies for women with a first singleton delivery from 1967 to 1994 were included and analysed in a cohort design using Cox regression.

RESULTS

Altogether, 639,018 women were included in the analyses, among whom 2204 women had diabetes mellitus before pregnancy. Their first pregnancy was complicated by pre-eclampsia in 13.2%, low birth weight offspring (<2.5 kg) in 11.0% and preterm birth in 25.1%, and their risk of ESRD and death in the follow-up period of up to 37 years was markedly higher. In women with pregestational diabetes, pre-eclampsia and preterm birth were associated with significantly increased risks of ESRD and death in women with only one pregnancy, but not in women with two or more pregnancies.

CONCLUSIONS

In women with pregestational diabetes, pre-eclampsia and preterm birth were associated with long-term increased risk of ESRD and death, but only in women who had only one pregnancy.

The association of intrauterine growth abnormalities in women with type 1 diabetes mellitus complicated by vasculopathy

OBJECTIVE

The purpose of this study was to test whether vasculopathy in type 1 diabetes mellitus (DM) is associated with fetal growth abnormalities.

STUDY DESIGN

Women with type 1 DM (n = 340) were enrolled in a prospective study of diabetes in pregnancy and classified according to vascular status: NV (no vasculopathy, n = 181), HBR (hypertension or background retinopathy, n = 79), PR (proliferative retinopathy only, n = 16), NEP (nephropathy only, n = 40), and PRN (proliferative retinopathy and nephropathy, n = 24). Association of vascular status with low birthweight (LBW) and small for gestational age (SGA) infants was analyzed.

RESULTS

The odds ratios for delivery of a LBW infant compared to women without vasculopathy after controlling for maternal age, gestational age and race were: HBR 1.0, PR 2.2, NEP 3.7, and PRN 5.5. The odds ratios for delivery of a SGA infant were: HBR 0.7, PR 10.4, NEP 1.9, and PRN 9.9.

CONCLUSION

Diabetic vasculopathy is associated with increased odds for delivery of low-birthweight or SGA infants.

Progression of retinopathy during pregnancy in type 1 diabetes mellitus

PURPOSE

The incidence and risk factors for progression of retinopathy during pregnancy in women with type 1 diabetes mellitus were retrospectively evaluated.

METHODS

Fifty-four insulin-dependent diabetic patients at a teaching hospital in Saudi Arabia were followed throughout the pregnancy/puerperium with serial ophthalmic examination. Dilated fundus examination was performed in each trimester and puerperium.

RESULTS

Progression of diabetic retinopathy in the study occurred in 13/54 (24%) patients--2/22 (9.1%) patients had no diabetic retinopathy initially, 4/20 (20%) had non-proliferative diabetic retinopathy (NPDR) and 7/12 (58.3%) had proliferative diabetic retinopathy (PDR). Of the eight patients with PDR who had no laser treatment before pregnancy, six (75%) showed progression but only one of the four patients who had PDR and laser treatment prior to pregnancy experienced progression of retinopathy. Eight patients in total received panretinal photocoagulation to arrest the progression of retinal disease during pregnancy and only one of them had laser treatment prior to pregnancy.

CONCLUSION

Laser photocoagulation for severe NPDR or early PDR prior to pregnancy may protect against rapid progression of PDR. Visual impairment resulting from progression of PDR can be prevented by aggressive laser treatment during pregnancy. Duration of diabetes>15 years, poor glycaemic control and hypertension are high-risk factors in the progression of diabetic retinopathy in pregnancy.

Maternal glycemic control and hypoglycemia in type 1 diabetic pregnancy: a randomized trial of insulin aspart versus human insulin in 322 pregnant women

OBJECTIVE

To assess the safety and efficacy of insulin aspart (IAsp) versus regular human insulin (HI) in basal-bolus therapy with NPH insulin in pregnant women with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Subjects (n = 322) who were pregnant or planning pregnancy were randomized to IAsp or HI as meal-time insulin in an open-label, parallel-group, multicenter study. Subjects had A1C < or =8% at confirmation of pregnancy. Insulin doses were titrated toward predefined glucose targets and A1C <6.5%. Outcomes assessed included risk of major maternal hypoglycemia, A1C, plasma glucose profiles, and maternal safety outcomes.

RESULTS

Major hypoglycemia occurred at a rate of 1.4 vs. 2.1 episodes/year exposure with IAsp and HI, respectively (relative risk 0.720 [95% CI 0.36-1.46]). Risk of major/major nocturnal hypoglycemia was 52% (RR 0.48 [0.20-1.143]; P = NS) lower with IAsp compared with HI. A1C was comparable with human insulin in second (IAsp-HI -0.04 [-0.18 to 0.11]) and third (-0.08 [-0.23 to 0.06]) trimesters. A total of 80% of subjects achieved an A1C < or =6.5%. At the end of first and third trimesters, average postprandial plasma glucose increments were significantly lower with IAsp than HI (P = 0.003 and P = 0.044, respectively), as were mean plasma glucose levels 90 min after breakfast (P = 0.044 and P = 0.001, respectively). Maternal safety profiles and pregnancy outcomes were similar between treatments.

CONCLUSIONS

IAsp is at least as safe and effective as HI when used in basal-bolus therapy with NPH insulin in pregnant women with type 1 diabetes and may potentially offer some benefits in terms of postprandial glucose control and preventing severe hypoglycemia.

Microvascular complications and the diabetic pregnancy

Without strict glycemic control, diabetic pregnancies are frequently complicated by spontaneous abortion, stillbirth, or congenital malformation. Retrospective studies have been largely reassuring that pregnancy does not accelerate morbid outcomes in women with diabetic vascular disease. Improved outcomes of high-risk pregnancy in women with pregestational, type 1, or type 2 diabetes mellitus remain challenging, depending on a comprehensive and multidisciplinary team approach and extensive preconception counseling.

Is pregnancy a risk factor for microvascular complications? The EURODIAB Prospective Complications Study

AIMS

To examine the long-term influence of pregnancy on the development and progression of microvascular complications in Type 1 diabetes.

METHODS

In the EURODIAB Prospective Complications Study (PCS), 793 women potentially child bearing at baseline completed the follow-up (7.3 years) and 163 (21%) gave birth during the follow-up period. We compared risk factors [mean levels of age, duration of diabetes, HbA(1c), systolic blood pressure (SBP) and proportion giving birth] between those that did or did not develop microvascular complications during the follow-up period.

RESULTS

For the 425 childless women at baseline, 102 gave birth during follow-up. HbA(1c) was a significant risk factor for progression to microalbuminuria but age, duration of diabetes, systolic blood pressure or giving birth were not. Duration of diabetes and high HbA(1c) were significant risk factors for progression to proliferative retinopathy, whereas giving birth was not. Similar results were obtained for progression to any form of retinopathy. Giving birth was not significantly related to the incidence of neuropathy. Similar results were obtained for women with children at baseline giving birth during follow-up (n = 61/368).

CONCLUSIONS

In this European study, having a first or another pregnancy did not seem to be a risk factor for long-term progression of any microvascular complication. This is in accordance with the findings of the Diabetes Control and Complications Trial (DCCT).

Preconception care of women with diabetes

Preconception care in women with diabetes reduces the risk of spontaneous abortion and congenital malformations as a result of improved glycemic control before and during organogenesis. Prepregnancy planning encompasses optimizing glycemic control and also affording the opportunity for genetic counseling, contraceptive selection, management of diabetes complications, and evaluation of psychosocial aspects of pregnancy, childbearing, and diabetes care. The purpose of this article is to provide nurses with current clinical assessment and management strategies of women with diabetes in order to implement a comprehensive individualized preconception plan of care.

A review of mothers' prenatal and postnatal quality of life

Background

Contemporary broad descriptions of health and well-being are reflected in an increasing appreciation of quality of life issues; in turn this has led to a growing number of tools to measure this.

Methods

This paper reviews articles cited in MEDLINE, CINAHL and BIDS which have addressed the concept of quality of life in pregnancy and the period following childbirth.

Results

It describes five groups of articles: those explicitly assessing quality of life in this area; those using broader health assessments as an indicator of quality of life; those articles equating quality of life with certain pregnancy outcomes in identified groups of patients; those studies which identify the possibility of pregnancy as an outcome measure and infer from this that quality of life has been improved; and those articles which are themselves reviews or commentaries of pregnancy and childbirth and which identify quality of life as a feature.

Conclusions

The term 'quality of life' is used inconsistently in the literature. There are few quality of life tools specifically designed for the maternity care setting. Improved or adversely affected quality of life is frequently inferred from certain clinical conditions.

Progression of retinopathy during pregnancy in type 1 diabetic women treated with insulin lispro

OBJECTIVE

To evaluate the progression of retinopathy during pregnancy and postpartum in (insulin-dependent) women with type 1 diabetes treated with insulin lispro or with regular human insulin.

RESEARCH DESIGN AND METHODS

A prospective open study of 69 pregnant women with diabetes was performed. A total of 36 of the women were treated with insulin lispro (lispro group) and 33 were treated with conventional short-acting human insulin (regular insulin group). The retinopathy level was estimated by color fundus photography every trimester and postpartum. Glycemic control during pregnancy, hypoglycemia (blood glucose level <3 mmol/l) in 24-h glucose profile, blood pressure, and proteinuria were registered.

RESULTS

HbA(1c) values were similar at baseline in the first trimester but thereafter were lower in the lispro group than in the regular insulin group throughout pregnancy (P = 0.022, repeated-measures ANOVA). The number of hypoglycemic episodes did not differ between the treatment groups. In multivariable logistic regression analysis with retinopathy severity (Diabetes Control and Complications Trial level) in the third trimester as the dependent variable, only nulliparity qualified as a predictor in the model [Exp(B) = 4.0, 95% CI 1.1-13.7, P = 0.030]. Factors such as duration of diabetes, type of insulin used, mean HbA(1c) level throughout pregnancy, blood pressure (systolic or diastolic), preeclampsia in the current pregnancy, smoking, or prepregnancy planning did not explain the retinopathy progression.

CONCLUSIONS

Insulin lispro improves glycemic control during diabetic pregnancy compared with regular insulin with no adverse impact on progression of diabetic retinopathy.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.