Prognosis of the outcome of pregnancies in diabetics. A new classification

Longitudinal Observation of Insulin Use and Glucose Sensor Metrics in Pregnant Women with Type 1 Diabetes Using Continuous Glucose Monitors and Insulin Pumps: The LOIS-P Study

Background: Suboptimal glycemic control is associated with maternal and neonatal morbidity and mortality in pregnancy complicated by type 1 diabetes (T1D). Prospective analysis of continuous glucose monitoring (CGM) metrics, insulin pump settings, and insulin delivery can better characterize the changes in glycemic levels and insulin use throughout pregnancy with T1D. Materials and Methods: Prescribed parameters, insulin delivery, carbohydrate intake, and CGM data for 25 pregnant women with T1D from three U.S. sites were collected. Participants enrolled before 17 weeks gestation and used personal insulin pumps and study CGM. Mean daily total, basal, and bolus insulin doses (units/kg), CGM time in range (TIR: 63-140 mg/dL), and pump-entered carbohydrates were analyzed for every 2-week gestational interval. Linear mixed-effects regression models were used to evaluate changes across gestational ages compared to 12-14 weeks. Results: Basal insulin was higher during weeks 6-12 and 24-40. Daily bolus and total insulin were higher during weeks 20-40. Pump parameters were adjusted to intensify insulin therapy from 22 weeks onward. Average TIR across pregnancy was 59% ± 14%. Between 18 and 30 weeks, TIR was significantly lower, and time above range was significantly higher compared to the reference biweek. Time below target was lower between 22 and 34 weeks. Seven participants achieved >70% recommended TIR for pregnancy. Participants with maternal complications or infant neonatal intensive care unit admissions had lower TIR. Conclusion: While insulin dosing changed significantly with advancing gestation, most participants did not achieve >70% TIR. Customized anticipatory pump setting adjustments and automated systems aimed toward the designated TIR are needed to improve outcomes for this population. NCT03761615.

Assessing White's classification of pregestational diabetes in a contemporary diabetic population

OBJECTIVE

To assess the validity of White's classification, including the role of chronic hypertension, in a contemporary diabetic population.

METHODS

We performed a retrospective cohort study of all singleton pregnancies with pre-existing diabetes mellitus from 2008 to 2013. Adverse outcomes were compared across classes B, C, D, and vascular disease (R, F, H) and further stratified by the presence or absence of chronic hypertension. Outcomes examined were a composite perinatal outcome (stillbirth, neonatal death, shoulder dystocia, birth injury, seizures, requiring chest compressions or intubation at delivery, blood pressure support), small for gestational age (SGA), large for gestational age (LGA), macrosomia, shoulder dystocia, preterm delivery at less than 37 weeks of gestation, preeclampsia, and cesarean delivery.

RESULTS

Of the 475 patients, the 1980 White's classification was significantly associated with SGA, LGA, macrosomia, preterm delivery, preeclampsia, and cesarean delivery (P≤.01). Within each White's class based on age or time since diagnosis alone, hypertension was significantly associated with a higher incidence of preeclampsia in class B (16% without hypertension compared with 32% with hypertension, P<.01) and C (22% compared with 40%, P=.04), SGA in C (4.7% compared with 21%, P<.01), preterm delivery in B (25% compared with 46%, P<.01) and C (35% compared with 58%, P=.01), and the composite neonatal outcome in B (7.9% compared with 17%, P=.03). The incidence of adverse outcomes in classes B and C with hypertension resembles the incidence of adverse outcomes in those with diabetes one class higher.

CONCLUSION

The 1980 White's classification system, taking into consideration the presence of chronic hypertension, remains a useful system for counseling pregestational diabetic women regarding adverse pregnancy outcomes.

LEVEL OF EVIDENCE

II.

Obstetric and diabetic care for pregnancy in diabetic women: 10 years outcome analysis, 1985-1995

AIM

Ten-year outcome analysis of all pregnancies in diabetic women in a population of 1.5 million people.

METHODS

Ascertainment of patients through the regional obstetrical computer, and by direct contact with each obstetrical unit. Retrospective assessment of early miscarriage of pregnancy from hospital records. Data are presented for the six smallest obstetrical units, the four smaller district hospitals, two larger teaching hospitals and for the regional referral centre.

RESULTS

Nine hundred and eighty-six fetal outcomes were identified, 753 in mothers treated with insulin before the pregnancy, 131 in mothers in whom insulin was started for the first time during the pregnancy and 102 in mothers treated by diet only. Overall perinatal mortality rates were 35.8 per 1000 for those mothers booked and delivered at a local maternity unit, 28.9 per 1000 for those booked and delivered at the regional centre, but 75.0 per 1000 for those who had booked locally but were transferred to the centre mid-pregnancy. Information on blood glucose control before and during pregnancy was relatively poorly documented. For the available data at the regional centre, only 160 of the 416 mothers had an identifiable preconception HbA1c measurement (mean 7.9%, range 3.3-16.8%): at booking 360 of these mothers had a mean HbA1c of 7.5% and by the third trimester mean HbA1c was 6.3% (range 3.3-13.2%).

CONCLUSIONS

The outcome of pregnancy in a diabetic mother in Northern Ireland remains a higher risk than for the general population. There is evidence that results in the regional centre are better, but problems arise when transfers occur mid-pregnancy. Measurement and recording of blood glucose control at all stages before and during pregnancy is incomplete. Diabet. Med. 18, 546-553 (2001)

Medical nutritional therapy in pregnant women with pregestational diabetes mellitus

OBJECTIVE

Diabetic women now can have the same chances as nondiabetic women to have a healthy infant. The reduction of risk associated with pregnancies complicated by diabetes can only be assured if normoglycemia is achieved before and during pregnancy. This review is intended to provide guidelines and scientific evidence for the optimal diet for the Type 1 or Type 2 diabetic woman.

METHODS

The literature over the past 10 years is presented. Those diets which achieved the best outcome of pregnancies complicated by diabetes (as evidenced by term delivery of a healthy, normal weight infant) are then outlined.

RESULTS

Diets which provide adequate calories without causing postprandial hyperglycemia or premeal ketosis are found to be based on body weight and gestational week of the pregnancy. Quantity of carbohydrate in the meal plan emerges as the most important component in achieving and maintaining glucose control.

CONCLUSIONS

The medical nutritional therapy for the Type 1 and Type 2 diabetic woman is a necessary component of the overall strategy to achieve and maintain normoglycemia and thus achieve the best outcome of pregnancy.

The management of diabetes in pregnancy

The aim of the diabetes specialist is to provide a service to the pregnant diabetic woman so that she will present to her obstetrician with such well-controlled plasma glucose levels that her pregnancy will proceed without any diabetes-related problem, and she will be delivered of a normal baby, of normal size, at the normal full-term gestation, by the normal route. There are some problems in achieving this aim. The exact definition of hyperglycaemia in pregnancy is still a matter of dispute. Screening methods to identify the problem differ widely. Many centres have developed joint diabetes/antenatal clinics, but there are practical problems with such an approach. Pre-pregnancy counselling, and discussion of contraceptive measures is an important task for the diabetologist and requires up-to-date knowledge. Control of plasma glucose requires alteration of insulin doses as pregnancy proceeds. Mothers with retinal, renal or cardiac problems will need special care. The medical problems which develop, and the management of blood glucose during labour and delivery, mean that the diabetes team must be very adjacent to the obstetric service, and a centralised approach offers many advantages. The postpartum state, and the long-term outcome for both mother and baby, remain both an interest and a responsibility for the obstetric physician.

The Art and Science of Maintenance of Normoglycemia in Pregnancies complicated by Insulin-Dependent Diabetes Mellitus

OBJECTIVE

To provide a "how-to" manual for achieving and maintaining normoglycemia in pregnant women with insulin-dependent diabetes.

METHODS

We describe a detailed program that has successfully maintained normoglycemia before, during, and after diabetes-complicated pregnancies. Insulin and glucose requirements throughout pregnancy, during labor, and in the postpartum period are outlined.

RESULTS

With preconception planning and careful dietary and blood glucose management during pregnancy, complications can be minimized and an optimal outcome of pregnancy can be achieved in women with diabetes.

CONCLUSION

Women with type I, insulin-dependent diabetes can now have the same chances as women without diabetes to have a healthy infant. The reduction of risks associated with pregnancies complicated by diabetes can be ensured if normoglycemia is achieved before and during the pregnancy.

The infant of the diabetic mother

The history of the medical success in treatment of the pregnant diabetic woman and her infant in the twentieth century illustrates how the combined efforts of dedicated clinicians and researchers have resulted in dramatic improvements in outcome for this patient group. This article discusses fetal growth, metabolic complications of the infant of the diabetic mother, risk of respiratory distress syndrome, hypertrophic cardiomyopathy, and congenital anomalies.

Nutrition management in women with gestational diabetes mellitus: a review by ADA's Diabetes Care and Education Dietetic Practice Group

Gestational diabetes mellitus (GDM) is the most common medical disorder complicating pregnancy that requires the services of a registered dietitian. Despite three international workshops on GDM, many questions remain regarding its epidemiology, pathophysiology, screening, diagnosis, and management. Registered dietitians encounter these controversial issues when working with women referred for GDM education and counseling. Nutrition intervention remains the cornerstone of therapy. The purpose of this article is not to provide practice guidelines but to review the literature and current practices in research centers across the United States. Registered dietitians are in a position to individualize nutrition care to each woman's needs and to participate in the decision-making process of nutrition management.

Congenital malformations in offspring of diabetic women treated with oral hypoglycaemic agents during embryogenesis

A markedly increased risk (50%) of congenital malformations in the offspring of women treated with oral hypoglycaemic agents during the first trimester has recently been reported. With this background, the medical records of a consecutive sample of 25 pregnant Type 2 diabetic women treated with oral hypoglycaemic agents during embryogenesis between 1966 and 1991 in the diabetic service of a university hospital, were studied retrospectively. None of the infants had major congenital malformations disclosed in the neonatal period (0%, 97.5% confidence interval 0.0-13.7%), but one minor congenital malformation was found (4.0%, 95% confidence interval 0.1-20.3%). Although this study, due to the limited number of pregnancies examined, does not exclude an association between treatment with oral hypoglycaemic agents at the time of embryogenesis and major congenital malformations in the offspring, the previously reported association was not confirmed. Thus we find no obvious indication for therapeutic abortions in patients who have accidentally been treated with oral hypoglycaemic agents during embryogenesis. On the contrary it seems reasonable to reassure these women with respect to their risk of having a malformed baby, stop the treatment with oral hypoglycaemic agents and initiate insulin treatment.

Managing diabetic patients with nephropathy and other vascular complications

Since the metabolic changes in normal pregnancy are diabetogenic, pregnancy imposes a severe stress on the metabolic milieu of diabetic patients. Moreover, many patients with long-standing diabetes have vascular complications, including retinopathy, renal insufficiency, nephrotic syndrome and hypertension, all representing separate risk factors for optimal fetal development. Recent experience has suggested that maternal hyperglycaemia, and associated fetal hyperinsulinaemia, may represent an important factor in the development of fetal complications. During the past two to three decades the incidence of perinatal deaths in all categories of diabetics has been reduced to a level that approaches the rate in healthy gravidas when severe congenital anomalies are excluded. Fetal and neonatal morbidity have also been reduced, although rates of congenital anomalies, hydramnios and respiratory distress syndrome remain high. Although the morbidity associated with oedema formation and hypertension is elevated, with meticulous management of patients with diabetic nephropathy, especially in the absence of severe renal insufficiency and/or severe hypertension, pregnancy performance and outcome can be similar to that of other insulin-dependent diabetic patients.

Obstetrical management of patients with diabetes in pregnancy

The management of the woman with diabetes diagnosed before the onset of pregnancy, or who develops it during pregnancy, requires a team approach involving the woman and her partner, the diabetes nurse educator, the dietitian, the endocrinologist, the obstetrician, the ultrasonologist and the paediatrician. It should start before pregnancy so that normoglycaemia is achieved before conception and maintained throughout gestation and labour. Fetoplacental surveillance commences with an early ultrasound to confirm fetal viability, repeated around 20 weeks to exclude major fetal malformations and then later in the third trimester to monitor fetal growth. CTG and biophysical profile assessment are major adjuncts to ensuring fetal well-being. The pregnancy should be allowed to go to full term when maternal blood glucose control has been satisfactory, fetal growth is within the normal range and other obstetrical complications, e.g. pre-eclampsia, are absent. Such an approach will ensure that the caesarean section rate can be minimized. During labour, the progress of labour and fetal well-being should be closely monitored. The woman who has microvascular complications of her diabetes (including proliferative retinopathy and nephropathy) requires even closer surveillance and premature delivery is more likely to be needed. The principles of management of the woman who develops gestational diabetes are similar, with even greater emphasis being placed on not inducing labour before full term unless complications dictate otherwise.

Preeclampsia in diabetic pregnancies

Diabetic pregnancies complicated by preeclampsia are of concern because of poor perinatal outcome. However, with improved maternal and fetal surveillance the impact of preeclampsia in diabetic pregnancies is declining. This prospective controlled study compared the incidence of preeclampsia and maternal-fetal outcome in 334 diabetic pregnancies and 16,534 nondiabetic pregnancies. The incidence of preeclampsia was 9.9% (33/334) in diabetic pregnancies compared with 4.3% (716/16,534) in nondiabetic controls. The incidence of preeclampsia rose with increasing severity of diabetes by White classification, but was still 8.9% after exclusion of diabetic patients with nephropathy or chronic hypertension. The perinatal mortality rate per 1000 births was 60 for preeclamptic diabetic patients compared with 3.3 for normotensive diabetic patients. Parity, maternal age, and blood glucose control were similar in preeclamptic diabetic patients compared with normotensive diabetic patients. We conclude that preeclampsia is twice as common in diabetic pregnancies compared with normal controls.

Myelination as a parameter of normal and retarded brain maturation

In this study a comparison of the myelination rate in humans in normal and pathologic conditions was made. The progress of myelination was examined on slides stained by the Klüver-Barrera method and evaluated as to four degrees. The prenatal myelination in the brain stem in a group of newborns who died of pregnancy pathology was correlated with normal brain stem myelination. Retardation of myelination by 2 to 10 weeks was found in cases with gestosis and diabetes in anamnesia. The myelin sheath formation in a group of children who died during the first three years of life after severe chronic diseases neoplastic and congenital heart failure was compared with the normal rate of postnatal myelination of the temporal lobe. The myelination process was evidently retarded by 2 to 20 months. The observations presented in this paper allowed the conclusion that pathologic conditions occurring in the maturing human may cause retarded maturation of myelin sheath.

Diabetes and pregnancy: need and use of intensive therapy

This paper explains the physiology of pregnancy and interrelates this information with the effects of pregnancy on the woman with pregestational diabetes mellitus. A review of the effects of diabetes on the fetus is presented, with information provided on the major complications that can negatively affect the fetus. The positive influence of intensive therapy on maternal and fetal outcome is stressed. The essential components of this therapy, along with possible variations in insulin treatment, are discussed. Emphasis is placed on the need for involving many disciplines in establishing this treatment.

Managing diabetic patients with nephropathy and other vascular complications

Since the metabolic changes in normal pregnancy are diabetogenic, pregnancy imposes a severe stress on the metabolic milieu of diabetic patients. Moreover, many patients with long-standing diabetes have vascular complications, including retinopathy, renal insufficiency, nephrotic syndrome and hypertension, that represent separate risk factors for optimal fetal development. Recent experience has suggested that maternal hyperglycaemia, and associated fetal hyperinsulinaemia, may represent an important factor in the development of fetal complications. During the past two to three decades the incidence of perinatal deaths has been reduced in all cases of diabetics to a level that approaches the rate in healthy gravidas when severe congenital anomalies are excluded. Fetal and neonatal morbidity have also been reduced, although rates of congenital anomalies, polyhydramnios and respiratory distress syndrome remain high. In patients with significant vascular complications, especially nephropathy and retinopathy, there is no evidence that pregnancy alters the natural course of these complications. Although the morbidity associated with oedema formation and hypertension is elevated, with meticulous management of patients with diabetic nephropathy, especially in the absence of severe renal insufficiency and/or severe hypertension, pregnancy performance and outcome can be similar to other insulin-dependent diabetics.

Reassessment of White's classification and Pedersen's prognostically bad signs of diabetic pregnancies in insulin-dependent diabetic pregnancies

The classification systems developed over 20 years ago by White and Pedersen identified diabetic pregnancies at increased risk for perinatal mortality. To assess whether these same criteria would currently be valid, 199 diabetic pregnancies with deliveries from 1977 to 1983 were reviewed. Perinatal mortality rates for White's Classes B gestational (n = 72), B (n = 27), C (n = 67), and D + F + R (n = 33) were 2.9%, 11.1%, 14.9%, and 21.1%, respectively (p less than 0.05). White's classes were also predictive of pulmonary morbidity (12.5%, 18.5%, 22.4%, and 42.4%, respectively). The presence of one or more of the prognostically bad signs of pregnancy (n = 76) increased the perinatal mortality rate to 17.1% versus 7.3% among insulin-dependent diabetic pregnancies without prognostically bad signs (p less than 0.05). The presence of any prognostically bad signs of pregnancy was also predictive of pulmonary morbidity in general (31.6% versus 16.3%, respectively) and hyaline membrane disease in particular (13.2% versus 4.1%, respectively). Thus with use of modern obstetric management and medical care of the pregnant diabetic patient, both White's classification and Pedersen's prognostically bad signs of pregnancy continue to be predictive of perinatal mortality.

Efficacy of mathematical methods for ultrasound examinations in diabetic pregnancies

The efficacy of a new principle for evaluation of fetal growth has been compared to standard methods in a population of pregnant diabetic women. Methods for projecting fetal weight at birth and determining the deviation of growth from an expected fetal weight increase based on our growth model provided significant information for the detection of fetal growth abnormalities 3 weeks (mean) before delivery. (Large for gestational age: sensitivity, 81%; specificity, 85%. Small for gestational age: sensitivity, 100%; specificity, 98%.) With the exception of two models for estimation of fetal weight based on ultrasound measurements of the fetal head and abdomen only, none of the standard methods gave results that were significantly better than the use of the biparietal diameter against a population standard. The new methods are expected to provide valuable information for the treatment of fetal growth disorders.

Congenital anomalies in offspring of insulin-dependent diabetic mothers

Congenital malformation continues to be a major problem for infants of diabetic mothers. Over a seven-year period, 199 insulin-requiring diabetic mothers were delivered at Vanderbilt University Medical Center. Con genital anomalies were identified in 26 (13%) newborns. There was no significant difference in the incidence of fetal anomalies between the various categories of White's classification of maternal diabetes mellitus. A review of proposed etiologies of anomalies in diabetic pregnancies is presented, and suggestions are made for the manage ment of women with dia betes desiring to conceive.

Ultrastructure of the villi and fetal capillaries of the placentas delivered by non-smoking diabetic women (White group D)

The ultrastructure of the placentas from nine non-smoking. White group D diabetic women were studied. The terminal villi showed changes in maturation, increased vascularization mainly due to very small vessels located at the periphery of the villus, and glycogen accumulation within the stroma cells and pericytes, corresponding to the known higher glycogen content of diabetic placentas. Multilaminal basement membrane surrounded the capillaries, but great variation appeared possibly due to variation in capillary age. It is suggested that diabetic metabolism induces a proliferative small vessel disease in combination with accelerated aging.

Psychiatric risk factors in the pregnant diabetic patient

One hundred pregnant diabetic patients have been prospectively studied in the first large-scale systematic evaluation of emotional behavior and psychosocial factors influencing psychiatric behavior in the pregnant diabetic patient. A Psychiatric Risk Scale including ten weighted medical and psychosocial factors has been developed to identify patients at high risk for psychiatric illness or poor compliance. This scale significantly increases the data base of classic "neglector" characteristics described by Pederson in 1965. Early identification of psychiatrically high-risk patients in concert with brief relevant psychodynamic exploration offers the potential of more directed care to a subset of patients at increased risk for poor perinatal performance.

Appraisal of "rigid" blood glucose control during pregnancy in the overtly diabetic woman

The degree of maternal glucose control achieved during the third trimester of pregnancy was evaluated for 120 overtly diabetic women hospitalized on a high-risk pregnancy ward. "Rigid" blood glucose control, defined as a mean preprandial plasma glucose concentration less than 115 mg/dl was achieved in only 14% of these women. Although mean preprandial plasmal glucose concentrations ranged between 115 and 172 mg/dl in 66% of women and exceeded 172 mg/dl in 20%, the perinatal salvage rate was greater than 95%. Pregnancies of those women whose mean plasma glucose levels exceeded 172 mg/dl required earlier intervention for signs of fetal jeopardy, but the degree of glucose control was not significantly related to either perinatal death or neonatal morbidity. These results suggest that maternal hyperglycemia exceeding a mean preprandial glucose concentration of 172 mg/dl is to be avoided, whereas, at the other extreme, mean glucose levels less than 115 mg/dl or "rigid" control is unnecessary for a successful perinatal outcome.

Gestational and pregestational diabetes: an approach to therapy

The objective of management in the pregnant diabetic patient is to achieve physiologic glucose homeostasis through the use of diet and insulin. As outlined, the numerous ancillary tests developed during the past 15 years to assist the clinician in determining impending fetal death have left much to be desired, especially where metabolic homeostasis has not been achieved prior to the thirty-sixth week of gestation. The statistics from this institution indicate that the maintenance of the plasma glucose concentration below 100 mg. per cent throughout gestation, regardless of the severity of the diabetes, all but removes the risk of maternal-fetal complications due to diabetes. The management is uniform for all patients exhibiting an abnormality of carbohydrate metabolism, and, although it is rather difficult to accept, there have been minimal neonatal complications when the protocol outlined in this presentation has been followed.