Prevention of congenital malformations in infants of insulin-dependent diabetic mothers

Hyperglycemia alters retinoic acid catabolism in embryos exposed to a maternal diabetic milieu

Pregestational diabetes is highly associated with increased risk of birth defects. We previously reported that the expression of Cyp26a1, the major catabolizing enzyme for controlling retinoic acid (RA) homeostasis, is significantly down-regulated in embryos of diabetic mice, thereby increasing the embryo's susceptibility to malformations caused by RA dysregulation. However, the underlying mechanism for the down-regulation of Cyp26a1 remains unclear. This study aimed to investigate whether elevated maternal blood glucose in the diabetic milieu is a critical factor for the altered Cyp26a1 expression. Streptozotozin-induced diabetic pregnant mice were treated with phlorizin (PHZ) to reduce blood glucose concentrations via induction of renal glucosuria. Embryonic Cyp26a1 expression level, RA catabolic activity and susceptibility to various RA-induced abnormalities were examined. To test the dose-dependent effect of glucose on Cyp26a1 level, early head-fold stage rat embryos of normal pregnancy were cultured in vitro with varying concentrations of D-glucose, followed by quantification of Cyp26a1 transcripts. We found that Cyp26a1 expression, which was down-regulated in diabetic pregnancy, could be normalized under reduced maternal blood glucose level, concomitant with an increase in RA catabolic activity in embryonic tissues. Such normalization could successfully reduce the susceptibility to different RA-induced malformations including caudal regression, cleft palate and renal malformations. The expression level of Cyp26a1 in the embryo was inversely correlated with D-glucose concentrations. Diabetic patients suffer from retinopathy, dermopathy, male infertility and increased cancer risk. Coincidentally, RA dysregulation is also associated with these health problems. Our results provided evidence that elevated glucose can down-regulate Cyp26a1 expression level and disturb RA homeostasis, shedding light on the possibility of affecting the health of diabetic patients via a similar mechanism.

A systematic review of maternal diabetes and congenital skeletal malformation

The magnitude of association of skeletal anomalies with maternal diabetes is not known. The systemic review was done to detect the frequency of congenital skeletal malformations with diabetes mellitus in pregnancy in the literature evidence of the past 50 years. Literature on maternal diabetes and skeletal malformation was searched by two independent authors by following PRISMA guidelines. Strict inclusion and exclusion criteria were followed. After quality assessment, 21 original articles were included. The frequency of congenital malformation, skeletal malformation was extracted from the included studies. 11,574 congenital anomalies were detected diabetic mothers. 1182 skeletal anomalies were noted in 20,11 552 diabetic mothers. The skeletal malformation was noted in 20.4% of total anomalies. The most common skeletal malformation was the defect of the spine (39.9%). The limb deficiency was found in 32.8% of the infants of diabetic mothers. The skeletal malformations were higher, that is, 24.6% in pre-gestational diabetes. The incidence of skeletal malformation from the evidence was 1.5% (range: 0.03-4.27%) in maternal diabetes. Pre-gestation diabetes is more frequently associated with skeletal malformations, which is 1.9% (range: 0.07-5.89%). The association of congenital malformations and skeletal malformations in diabetic pregnancy is significant and hence, effective management of diabetes in childbearing age is essential to reduce this incidence and related long-term morbidity.

Awareness of Preconception Care and Its Related Factors Among Women of Childbearing Age with Type 1 Diabetes in the South of Saudi Arabia: A Cross-Sectional Survey Study

BACKGROUND

Pregnancies in women with type 1 diabetes mellitus (T1DM) are associated with an increased risk of poor outcomes for mothers and their infants.

OBJECTIVE

To assess the awareness of preconception care among women with T1DM and their self-management status in the southern region of Saudi Arabia.

METHODS

This study is a cross-sectional study that was done on 187 women participated of childbearing age with T1DM who were seen in diabetic centers between June 2019 and September 2020. Pre-pregnancy care and disease management were assessed via a questionnaire.

RESULTS

The prevalence of preconception awareness of diabetes management was 66.9%. Several factors significantly influenced the level of awareness, including education level (P= 0.001) and HbA1c (P= 0.014). In multivariate analysis, the lower educational level turns out to be a significant risk factor for low awareness (OR = 3.71, 95% CI [1.65, 8.31], P= 0.001). Additionally, compared to controlled DM, uncontrolled diabetes had a twofold increased risk of low awareness (OR = 2.03, 95% CI [1.08, 3.81], P= 0.027).

CONCLUSION

The awareness level was significantly correlated with a high educational level and better glycemic control. Meanwhile, it was not significantly correlated with diabetes duration.

Effects of Gestational Diabetes in Cognitive Behavior, Oxidative Stress and Metabolism on the Second-Generation Off-Spring of Rats

Gestational diabetes (GD) has a negative impact on neurodevelopment, resulting in cognitive and neurological deficiencies. Oxidative stress (OS) has been reported in the brain of the first-generation offspring of GD rats. OS has been strongly associated with neurodegenerative diseases. In this work, we determined the effect of GD on the cognitive behavior, oxidative stress and metabolism of second-generation offspring. GD was induced with streptozotocin (STZ) in pregnant rats to obtain first-generation offspring (F1), next female F1 rats were mated with control males to obtain second-generation offspring (F2). Two and six-month-old F2 males and females were employed. Anxious-type behavior, spatial learning and spatial working memory were evaluated. In cerebral cortex and hippocampus, the oxidative stress and serum biochemical parameters were measured. Male F2 GD offspring presented the highest level of anxiety-type behavior, whilst females had the lowest level of anxiety-type behavior at juvenile age. In short-term memory, adult females presented deficiencies. The offspring F2 GD females presented modifications in oxidative stress biomarkers in the cerebral cortex as lipid-peroxidation, oxidized glutathione and catalase activity. We also observed metabolic disturbances, particularly in the lipid and insulin levels of male and female F2 GD offspring. Our results suggest a transgenerational effect of GD on metabolism, anxiety-like behavior, and spatial working memory.

Time in Range in Pregnancy: Is There a Role?

Continuous glucose monitoring (CGM) is being used with increasing frequency as an adjunct to self-monitoring of blood glucose in pregnancy, and novel targets based on CGM data are becoming standardized. This adoption of CGM is the result of its improving accuracy, patient preference, and evolving data demonstrating associations of novel targets such as time in range (TIR) with pregnancy and neonatal outcomes. A greater understanding of the relationship of various CGM metrics to outcomes in pregnancy complicated by diabetes is needed. It is clear that TIR parameters need to be uniquely lower for pregnant women than for nonpregnant individuals. CGM technology is also an integral part of hybrid closed-loop insulin delivery systems. These insulin delivery systems will be a significant advance in the management of diabetes during pregnancy if they can achieve the pre- and postprandial targets required for pregnancy and optimize TIR.

Association of Maternal Prepregnancy Diabetes and Gestational Diabetes Mellitus With Congenital Anomalies of the Newborn

OBJECTIVE

To examine the association of maternal prepregnancy diabetes, gestational diabetes mellitus (GDM), and 12 subtypes of congenital anomalies of the newborn.

RESEARCH DESIGN AND METHODS

We included 29,211,974 live births with maternal age ranging from 18 to 49 years old documented in the National Vital Statistics System in the U.S. from 2011 to 2018. Information on prepregnancy diabetes, GDM, and congenital anomalies was retrieved from birth certificates. Log-binomial regression was used to estimate risk ratios (RRs) and 95% CIs for congenital anomalies overall and by subtypes.

RESULTS

Of the 29,211,974 live births, there were 90,061 infants who had congenital anomalies identified at birth. The adjusted RRs of congenital anomalies at birth were 2.44 (95% CI 2.33-2.55) for prepregnancy diabetes and 1.28 (95% CI 1.24-1.31) for GDM. The associations were generally consistent across subgroups by maternal age, race/ethnicity, prepregnancy obesity status, and infant sex. For specific subtypes of congenital anomalies, maternal prepregnancy diabetes or GDM was associated with an increased risk of most subtypes. For example, the adjusted RRs of cyanotic congenital heart disease were 4.61 (95% CI 4.28-4.96) for prepregnancy diabetes and 1.50 (95% CI 1.43-1.58) for GDM; the adjusted RRs of hypospadias were 1.88 (95% CI 1.67-2.12) for prepregnancy diabetes and 1.29 (95% CI 1.21-1.36) for GDM.

CONCLUSIONS

Prepregnancy diabetes and, to a lesser extent, GDM were associated with several subtypes of congenital anomalies of the newborn. These findings suggest potential benefits of preconception counseling in women with preexisting diabetes or at risk for GDM for the prevention of congenital anomalies.

MiR-302 Regulates Glycolysis to Control Cell-Cycle during Neural Tube Closure

Neural tube closure is a critical early step in central nervous system development that requires precise control of metabolism to ensure proper cellular proliferation and differentiation. Dysregulation of glucose metabolism during pregnancy has been associated with neural tube closure defects (NTDs) in humans suggesting that the developing neuroepithelium is particularly sensitive to metabolic changes. However, it remains unclear how metabolic pathways are regulated during neurulation. Here, we used single-cell mRNA-sequencing to analyze expression of genes involved in metabolism of carbon, fats, vitamins, and antioxidants during neurulation in mice and identify a coupling of glycolysis and cellular proliferation to ensure proper neural tube closure. Using loss of miR-302 as a genetic model of cranial NTD, we identify misregulated metabolic pathways and find a significant upregulation of glycolysis genes in embryos with NTD. These findings were validated using mass spectrometry-based metabolite profiling, which identified increased glycolytic and decreased lipid metabolites, consistent with a rewiring of central carbon traffic following loss of miR-302. Predicted miR-302 targets Pfkp, Pfkfb3, and Hk1 are significantly upregulated upon NTD resulting in increased glycolytic flux, a shortened cell cycle, and increased proliferation. Our findings establish a critical role for miR-302 in coordinating the metabolic landscape of neural tube closure.

Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes

Background

Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes.

Methods

Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence.

Results

The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence).

Conclusion

PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.

Care of Infants Born to Women with Diabetes

PURPOSE OF REVIEW

Infants of women with diabetes are at risk for specific morbidities including congenital anomalies, abnormalities of fetal growth, neonatal hypoglycemia, electrolyte abnormalities, polycythemia, hyperbilirubinemia, and respiratory distress syndrome. Recent studies have shed light on long-term outcomes of these infants and presented advances in treatment. The purpose of this review is to outline the most common neonatal morbidities affecting infants of women with diabetes, the pathophysiology and prevalence of these conditions, and contemporary approaches to treatment.

RECENT FINDINGS

Recent investigative findings have led to advances in treatment approaches for these infants, particularly regarding risks of neonatal hypoglycemia. Optimizing maternal glycemic control during pregnancy is imperative to improving infant outcomes. However, on a population level, maternal diabetes still poses significant risks to the infant. Timely and appropriate treatment of infants of women with diabetes is imperative to decrease short- and long-term morbidity.

Descriptive and risk factor analysis of nonsyndromic sacral agenesis: National Birth Defects Prevention Study, 1997-2011

Sacral agenesis is a rare birth defect characterized by partial or complete absence of the sacrum. We sought to (a) describe case characteristics, (b) estimate birth prevalence, and (c) identify risk factors for nonsyndromic sacral agenesis using data from the National Birth Defects Prevention Study (NBDPS). The NBDPS was a population-based, case-control study involving pregnancies with estimated dates of delivery from October 1997 through December 2011. We estimated birth prevalence using all NBDPS eligible cases. Using self-reported maternal exposure information, we conducted multivariable logistic regression analysis to identify potential risk factors overall and among women without diabetes. The birth prevalence of sacral agenesis was 2.6/100,000 live births. In the multivariable analysis, multifetal pregnancy, pre-existing Type 1 diabetes, and pre-existing Type 2 diabetes were positively and significantly associated with sacral agenesis, albeit estimates were imprecise. Preexisting Type 1 diabetes was the strongest risk factor (adjusted odds ratio = 96.6, 95% confidence interval = 43.5-214.7). Among women without diabetes, periconceptional smoking was positively and significantly associated with sacral agenesis. Our findings underscore the importance of smoking cessation programs among women planning pregnancy and the importance of better understanding the role of glycemic control before and during pregnancy when designing interventions for primary prevention of sacral agenesis.

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.

Daily walking is effective for the management of pregnant women with gestational diabetes mellitus

Aim

This study evaluated the usefulness of daily walking for gestational diabetes mellitus (GDM) management by analyzing the relationship between daily walking and glucose tolerance in pregnant women with GDM who were in the second trimester.

Methods

This longitudinal study was conducted at TOYOTA Memorial Hospital in Toyota, Japan, from January 2015 to June 2016. Pregnant women with GDM wore accelerometers on the waist for 7–12 weeks.

Results

Seventy‐three women with GDM were included in the present study; data collected from 24 women were analyzed. The estimated number of steps walked daily showed a significant positive correlation (r = 0.798, P = 0.000) with energy expenditure related to physical activity. There was a significant negative correlation (r = −0.603, P = 0.014) between the post‐ to pre‐research casual glucose level (CGL) ratio and the number of steps walked daily. No significant correlation (r = −0.004, P = 0.986) was detected between the ratio of hemoglobin A_1c and the number of steps taken. When the study was completed, the 11 participants who walked ≥6000 steps/day showed significantly lower CGL (95 + 10 mg/dL [mean + SD]) than the 13 participants in the <6000 steps/day group (111 + 18 mg/dL) (P = 0.013).

Conclusion

Simple walking for light intensity physical activity is effective for controlling the CGL in pregnant women with GDM. We recommend that pregnant women with GDM should walk a minimum of 6000 steps/day.

Perinatal mortality in Japanese women diagnosed with gestational diabetes mellitus and diabetes mellitus

AIMS

The objective of this study was to determine how many pregnant Japanese women with diabetes mellitus (DM)/gestational diabetes mellitus (GDM) experience perinatal mortality in the presence of fetal anomalies.

METHODS

Our investigation included data from 205 secondary/tertiary obstetric facilities located widely in Japan. The Japan Ministry of Health, Labour and Welfare Vital Statistics of Japan was used for comparison.

RESULTS

Of 237 941 women giving birth at 205 hospitals, 1796 (0.8%) and 13 037 (5.5%) had DM and GDM, respectively. The perinatal mortality rates (per 1000 births) were 10.6 (19/1796) for women with DM, 5.2 (68/13037) for women with GDM, and 3.7 (7612/2039504) for the general Japanese population. Detailed information was available for 63 (72%) of the 87 perinatal deaths occurring in women with diabetes including DM and GDM; fetal anomalies were associated with 40% (25/63) of perinatal deaths, exceeding 16% (1211/7612) in the general Japanese population (P < 0.0001). The leading four fetal anomalies associated with perinatal mortality in women with diabetes were fetal trisomy (6 cases: 1 of trisomy-13 and 5 of trisomy-18), non-immune hydrops fetalis (5 cases), cardiac deformities (3 cases) and holoprosencephaly (2 cases).

CONCLUSIONS

Perinatal mortality was more likely to occur in women with glucose intolerance. In the Japanese infants that succumbed to perinatal mortality, fetal anomaly was more prevalent in those born to women with a glucose intolerance than in those born to the general population.

A core outcome set for studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes

AIMS/HYPOTHESIS

The aim of this study was to develop a core outcome set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational (pre-existing) diabetes mellitus.

METHODS

A systematic literature review was completed to identify all outcomes reported in prior studies in this area. Key stakeholders then prioritised these outcomes using a Delphi study. The list of outcomes included in the final COS were finalised at a face-to-face consensus meeting.

RESULTS

In total, 17 outcomes were selected and agreed on for inclusion in the final COS. These outcomes were grouped under three domains: measures of pregnancy preparation (n = 9), neonatal outcomes (n = 6) and maternal outcomes (n = 2).

CONCLUSIONS/INTERPRETATION

This study identified a COS essential for studies evaluating prepregnancy care for women with pregestational diabetes. It is advocated that all trials and other non-randomised studies and audits in this area use this COS with the aim of improving transparency and the ability to compare and combine future studies with greater ease.

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

BACKGROUND

Self-monitoring of blood glucose (SMBG) is recommended as a key component of the management plan for diabetes therapy during pregnancy. No existing systematic reviews consider the benefits/effectiveness of various 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.

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

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), searched reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM) 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 included. 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 at total of 10 trials (538) women (468 women with type 1 diabetes and 70 women with type 2 diabetes). The trials took place in Europe and the USA. Five of the 10 included studies were at moderate risk of bias, four studies were at low to moderate risk of bias, and one study was at high risk of bias. The trials are too small to show differences in important outcomes such as macrosomia, preterm birth, miscarriage or death of baby. Almost all the reported GRADE outcomes were assessed as being very low-quality evidence. This was due to design limitations in the studies, wide confidence intervals, small sample sizes, and few events. In addition, there was high heterogeneity for some outcomes.Various methods of glucose monitoring were compared in the trials. Neither pooled analyses nor individual trial analyses showed any clear advantages of one monitoring technique over another for primary and secondary outcomes. Many important outcomes were not reported.1. Self-monitoring versus standard care (two studies, 43 women): there was no clear difference for caesarean section (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.40 to 1.49; one study, 28 women) or glycaemic control (both very low-quality), and not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Hypertensive disorders of pregnancy, large-for-gestational age, neurosensory disability, and preterm birth were not reported in either study.2. Self-monitoring versus hospitalisation (one study, 100 women): there was no clear difference for hypertensive disorders of pregnancy (pre-eclampsia and hypertension) (RR 4.26, 95% CI 0.52 to 35.16; very low-quality: RR 0.43, 95% CI 0.08 to 2.22; very low-quality). There was no clear difference in caesarean section or preterm birth less than 37 weeks' gestation (both very low quality), and the sample size was too small to assess perinatal mortality (very low-quality). Large-for-gestational age, mortality or morbidity composite, neurosensory disability and preterm birth less than 34 weeks were not reported.3. Pre-prandial versus post-prandial glucose monitoring (one study, 61 women): there was no clear difference between groups for caesarean section (RR 1.45, 95% CI 0.92 to 2.28; very low-quality), large-for-gestational age (RR 1.16, 95% CI 0.73 to 1.85; very low-quality) or glycaemic control (very low-quality). The results for hypertensive disorders of pregnancy: pre-eclampsia and perinatal mortality are not meaningful because these outcomes were too rare to show differences in a small sample (all very low-quality). The study did not report the outcomes mortality or morbidity composite, neurosensory disability or preterm birth.4. Automated telemedicine monitoring versus conventional system (three studies, 84 women): there was no clear difference for caesarean section (RR 0.96, 95% CI 0.62 to 1.48; one study, 32 women; very low-quality), and mortality or morbidity composite in the one study that reported these outcomes. There were no clear differences for glycaemic control (very low-quality). No studies reported hypertensive disorders of pregnancy, large-for-gestational age, perinatal mortality (stillbirth and neonatal mortality), neurosensory disability or preterm birth.5.CGM versus intermittent monitoring (two studies, 225 women): there was no clear difference for pre-eclampsia (RR 1.37, 95% CI 0.52 to 3.59; low-quality), caesarean section (average RR 1.00, 95% CI 0.65 to 1.54; I² = 62%; very low-quality) and large-for-gestational age (average RR 0.89, 95% CI 0.41 to 1.92; I² = 82%; very low-quality). Glycaemic control indicated by mean maternal HbA1c was lower for women in the continuous monitoring group (mean difference (MD) -0.60 %, 95% CI -0.91 to -0.29; one study, 71 women; moderate-quality). There was not enough evidence to assess perinatal mortality and there were no clear differences for preterm birth less than 37 weeks' gestation (low-quality). Mortality or morbidity composite, neurosensory disability and preterm birth less than 34 weeks were not reported.6. Constant CGM versus intermittent CGM (one study, 25 women): there was no clear difference between groups for caesarean section (RR 0.77, 95% CI 0.33 to 1.79; very low-quality), glycaemic control (mean blood glucose in the 3rd trimester) (MD -0.14 mmol/L, 95% CI -2.00 to 1.72; very low-quality) or preterm birth less than 37 weeks' gestation (RR 1.08, 95% CI 0.08 to 15.46; very low-quality). Other primary (hypertensive disorders of pregnancy, large-for-gestational age, perinatal mortality (stillbirth and neonatal mortality), mortality or morbidity composite, and neurosensory disability) or GRADE outcomes (preterm birth less than 34 weeks' gestation) were not reported.

AUTHORS' CONCLUSIONS

This review found no evidence that any glucose monitoring technique is superior to any other technique among pregnant women with pre-existing type 1 or type 2 diabetes. The evidence base for the effectiveness of monitoring techniques is weak and additional evidence from large well-designed randomised trials is required to inform choices of glucose monitoring techniques.

Diabetes Nurse Educators and Preconception Counseling

Purpose: The purpose of this study was to examine the diabetes nurse educator’s role, practice, and training in preconception counseling (PC) when caring for adolescents with diabetes.

Methods: A descriptive, correlational research design, using a cross-sectional survey technique, was used. Subjects were 2003 registered nurse members of the American Association of Diabetes Educators. A survey instrument was developed by the investigator and placed on the World Wide Web.

Results: Although most of the diabetes nurse educators were aware of PC, most reported not having received any training in PC and would benefit from this education. Thirty percent of the respondents did not routinely provide PC to their adult female clients, and 40% did not provide this to adolescents.

Conclusions: Results of this study suggest that the diabetes nurse educators in this sample would benefit from receiving instruction about PC. The diabetes nurse educators should be trained to provide PC to all female clients with diabetes of childbearing age starting at puberty.

Improving outcomes of pregnancy for women with type 1 and type 2 diabetes

The pregnancy outcomes for women with type 1 diabetes remain poor with increased risk of major congenital malformation, stillbirth, premature delivery and perinatal death compared to the background maternity population. Despite clear evidence that women who attend prepregnancy care have improved blood glucose control with reduced risk of serious adverse outcomes, only a minority of women attend these clinics. For women with type 2 diabetes who are older, more obese and more likely to belong to an ethnic minority or live in an area of social deprivation, pregnancy outcomes are at least as poor as for women with type 1 diabetes. This is important as the prevalence of type 2 diabetes in women of reproductive years is increasing and even fewer women with type 2 diabetes attend prepregnancy care or take folic acid supplementation. Greater awareness regarding the risks among women with diabetes as well as primary and secondary healthcare professionals is required, if pregnancy outcomes are to be improved.

Morphofunctional renal alterations in rats induced by intrauterine hyperglycemic environment

INTRODUCTION

The renal development of rats begins in intrauterine life, finishing by 15 days after birth. Diabetes and other diseases during pregnancy can cause systemic changes in the offspring. We evaluated the structural and functional renal alterations of the offspring from diabetic mothers.

MATERIAL AND METHODS

Pregnant rats were separated and 1, 7, 30 and 90 days-old (DO) pups were divided into groups according to the treatment that the mothers received: G1: control, G2: untreated diabetic and G3: insulin-treated diabetic. The kidneys from offspring at 1, 7 and 30 DO were removed for immunohistochemical and histological studies. Furthermore, blood and urine samples were collected from animals at 30 DO to determine the glomerular filtration rate (GFR) by creatinine clearance, and the animals at 90 DO were subjected to blood pressure measurement by plethysmography.

RESULTS

Our results show an increase of PCNA(+) glomerular cells at 7 DO and a reduction in 30 DO animals as well as increased α-smooth muscle actin (α-SMA) tubulointerstitial expression at 1 and 7 DO in animals from G2, when compared with controls. The adult offspring from G2 showed reduced GFR and increased blood pressure.

CONCLUSIONS

Maternal diabetes may have induced programming of renal damage in offspring of hyperglycemic mothers, which may have contributed to the impairment of renal function.

Effects of Self-Efficacy and Locus of Control on Future Preconception Counseling Plans of Adult Women With Type 1 Diabetes

Objective. The American Diabetes Association (ADA) recommends that women with diabetes attend preconception counseling and improve blood glucose levels before pregnancy to decrease risks of adverse outcomes. However, two-thirds of women with diabetes do not plan their pregnancies. Research has examined views regarding preconception counseling of pregnant women with diabetes, but perceptions of women with diabetes who have never been pregnant have not been explored. The purpose of this study was to examine the relationship between women's locus of control, self-efficacy, and outcome expectations of preconception counseling. Design and Methods. A sample of 147 nulligravid women with type 1 diabetes (mean age 25.9 years) was recruited online to complete a self-report survey. Measures included a sociodemographics form, a study-specific questionnaire regarding diabetes management and education, the Reproductive Health Attitudes and Behaviors instrument, and the Diabetes-Specific Locus of Control measure. Results. A standard multiple linear regression analysis indicated that self-efficacy was positively associated with expectations of preconception counseling (P <0.001), whereas self-blame was negatively associated (P = 0.001). Three-fourths of the women reported not receiving preconception counseling from health care providers. Conclusion. Self-efficacy was positively associated with women's expectation of preconception counseling usefulness, whereas self-blame for poor disease management was inversely related. The low reported rates of preconception counseling demonstrate that ADA recommendations for starting preconception counseling at puberty have not been followed uniformly. Women with diabetes should be provided education to increase their belief that they have control over their disease, which may lead to positive perceptions of preconception counseling and healthier pregnancies.

[Pregravid preparation of diabetic women]

Pregnancy in women with type 1 or 2 diabetes mellitus (DM) is associated with an increased risk for complications in both the mother and her fetus. The impact of these complications on modifiable risk factors may substantially improve pregnancy outcomes and reduce malformation rates in children. This is a goal of pregravid preparation (PGP) in this category of patients. The review gives the main points of PGP in patients with types 1 and DM and shows the results of main studies providing evidence for PGP in DM. In particular, by the moment of conception, DM patients should achieve a glycosylated hemoglobin (HbA1c) goal of <6% no later than 4 weeks before conception and during the first trimester of pregnancy, take folic acid in a high dose (at least 4000 µg, or 4 mg, daily), quit tobacco smoking and alcohol use, receive potentially teratogenic drugs, and, if need be, lose weight (the target body mass index of <27 kg/m2).

Impact of pre-pregnancy diabetes mellitus on congenital anomalies, Canada, 2002-2012

OBJECTIVE

To examine the impact of pre-pregnancy diabetes mellitus (DM) on the population birth prevalence of congenital anomalies in Canada.

METHODS

We carried out a population-based study of all women who delivered in Canadian hospitals (except those in the province of Quebec) between April 2002 and March 2013 and their live-born infants with a birth weight of 500 grams or more and/or a gestational age of 22 weeks or more. Pre-pregnancy type 1 or type 2 DM was identified using ICD-10 diagnostic codes. The association between DM and all congenital anomalies as well as specific congenital anomaly categories was estimated using adjusted odds ratios; the impact was calculated as a population attributable risk percent (PAR%).

RESULTS

There were 118,892 infants with a congenital anomaly among 2,839,680 live births (41.9 per 1000). While the prevalence of any congenital anomaly declined from 50.7 per 1000 live births in 2002/03 to 41.5 per 1000 in 2012/13, the corresponding PAR% for a congenital anomaly related to pre-pregnancy DM rose from 0.6% (95% confidence interval [CI]: 0.4-0.8) to 1.2% (95% CI: 0.9-1.4). Specifically, the PAR% for congenital cardiovascular defects increased from 2.3% (95% CI: 1.7-2.9) to 4.2% (95% CI: 3.5-4.9) and for gastrointestinal defects from 0.8% (95% CI: 0.2-1.9) to 1.4% (95% CI: 0.7-2.6) over the study period.

CONCLUSION

Although there has been a relative decline in the prevalence of congenital anomalies in Canada, the proportion of congenital anomalies due to maternal pre-pregnancy DM has increased. Enhancement of preconception care initiatives for women with DM is recommended.

Preconception care: screening and management of chronic disease and promoting psychological health

INTRODUCTION

A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33).

CONCLUSION

While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

The preconceptional period as an opportunity for prediction and prevention of noncommunicable disease

Preconceptional care is a set of interventions, aimed to identify and modify medical, behavioral, and social risks to a woman's health and her pregnancy outcome, prior to conception. Diagnosing and treating some of the common noncommunicable diseases (NCDs) may have an impact on pregnancy outcome. Ample time should be allowed to properly intervene in some of the following situations: hypertension, diabetes, obesity, systemic lupus erythematosus, thyroid disease, anemia, epilepsy, asthma, and cardiac disease. Diabetes mellitus and obesity are common NCDs, with proven efficacy for preconceptional care, for both maternal and perinatal outcome. These primary components of the metabolic syndrome, if properly treated prior to pregnancy, will prevent long-term hazards for the mother, her children, and the next generations, by providing in utero primary prevention of NCDs.

Psychosocial influences on glycemic control in women with pre-existing diabetes preparing for pregnancy

OBJECTIVE

The purpose of this study was to identify psychosocial factors associated with glycemic control in a sample of adult women with type 1 or type 2 diabetes mellitus preparing for pregnancy.

METHODS

This was a cross-sectional study. Participants comprised a subsample (n=38) of a larger study investigating predictors of prepregnancy care uptake in women with pre-existing diabetes. Participants were recruited from the diabetes and pregnancy clinics at 2 major hospitals and completed self-report questionnaires on personality, coping style, social support and knowledge of diabetes and pregnancy. The main outcome was glycemic control using glycated hemoglobin (A1C) as the outcome of interest.

RESULTS

The sample was divided into good (n=20) vs. poor (n=18) glycemic control based on their A1C at entry to the study. Univariate tests indicated no differences between the 2 groups on any of the variables except that the good control group were better educated. Hierarchical multiple regression analysis revealed that problem-focused coping and higher education remained significantly associated with better glycemic control when controlling for potential confounds.

CONCLUSIONS

Providing women with enhanced prepregnancy diabetes education with a particular emphasis on problem-solving and coping skills may enable them to take more proactive approaches to challenges they face in managing their diabetes. That in turn can improve glycemic control at the critical period.

The effect of pre-existing maternal obesity and diabetes on placental mitochondrial content and electron transport chain activity

INTRODUCTION

Mitochondria dysfunction has been extensively implicated in the progression of these metabolic disorders, their role in placental tissue of diabetic and/or obese pregnant women is yet to be investigated. The aim of this study was to determine the effect of pre-existing type 1 and type 2 diabetes mellitus (DM), and pre-existing maternal obesity on placental mitochondrial function as assessed by mitochondrial content, electron transport chain (ETC) complex activities and oxidative stress.

METHODS

Human placenta was obtained at the time of term Caesarean section from (i) non-obese (n = 19) and obese (n = 23) normal glucose tolerant (NGT) pregnant women; (ii) women with type 1 DM (n = 14) and BMI-matched NGT women (n = 14); and (iii) women with type 2 DM (n = 11) and BMI-matched NGT women (n = 11). The following endpoints were assessed: placental mitochondrial content by citrate synthase activity and mitochondrial DNA (mtDNA content); mitochondrial respiratory chain activity (complexes I, II, II & III, III and IV), and mitochondrial ROS (as assessed by mitochondrial hydrogen peroxide (H2O2) levels).

RESULTS

When compared to placenta from NGT non-obese women, there was significantly lower mitochondrial DNA (mtDNA) content and electron transport chain complex I activity, and significantly higher mitochondrial H2O2 levels in placenta from NGT obese women (P < 0.05). Placental tissue from type 1 DM women showed significant reductions in ETC complex I, II & III, and III activity and increased H2O2 levels when compared to BMI-matched NGT women (P < 0.05). Type 2 DM women only exhibited significantly reduced ETC complex II & III activity when compared to BMI-matched NGT women (P < 0.05).

DISCUSSION AND CONCLUSIONS

Women with pre-existing obesity or diabetes have decreased placental mitochondrial respiratory chain enzyme activities which may have detrimental consequences on placental function and therefore fetal growth and development.

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

BACKGROUND

Self-monitoring of blood glucose is recommended as a key component of the management plan for diabetes therapy during pregnancy. No existing systematic reviews consider the benefits/effectiveness of various 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.

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

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 August 2013), searched reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing techniques of blood glucose monitoring including self blood glucose monitoring, continuous glucose monitoring (CGM) 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 included. Quasi-RCTs and 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.

MAIN RESULTS

The search of the Pregnancy and Childbirth Group's Trials Register identified 21 trial reports. Following application of eligibility criteria, nine trials were included in this review. The included trials involved a total of 506 women (436 women with Type 1 diabetes and 70 women with Type 2 diabetes). All trials originated from European countries and the USA. None of the studies included women with gestational diabetes. Five of the nine included studies were at moderate risk of bias and four studies were at low to moderate risk of bias. Primary outcomes were maternal glycaemic control (fasting blood glucose and HbA1c) and infant birthweight or macrosomia.Various methods of glucose monitoring were compared in the trials. The following comparisons were included in the review: (1) self-monitoring versus standard care, (2) self-monitoring versus hospitalisation, (3) pre-prandial versus post-prandial glucose monitoring, (4) automated telemedicine monitoring versus conventional system, (5) CGM versus intermittent monitoring and (6) constant CGM versus intermittent CGM.Neither pooled analyses nor individual trial analyses showed any significant advantages of one monitoring technique over another for primary outcomes (maternal glycaemic control and infant birthweight) and secondary outcomes such as gestational age at birth or preterm birth, frequency of neonatal hypoglycaemia, death of baby including stillbirth, and neonatal intensive care admission. Primary outcome data on macrosomia were reported by one trial but at a different cut-off value than that pre-specified for the review. Secondary outcomes such as shoulder dystocia, major and minor anomalies were not reported by any of the trials.

AUTHORS' CONCLUSIONS

This review found no evidence that any glucose monitoring technique is superior to any other technique among pregnant women with pre-existing Type 1 or Type 2 diabetes. The evidence base for the effectiveness of monitoring techniques is weak and additional evidence from large well-designed randomised trials is required to inform choices of glucose monitoring techniques.

Hemoglobin A1c in pregestational diabetic gravidas and the risk of congenital heart disease in the fetus

This study aimed to determine whether poor glycemic control in early pregnancy is associated with an increased risk of congenital heart disease (CHD) for infants of women with preexisting diabetes. A retrospective review examined two tertiary care centers of diabetic pregnancies that recorded early hemoglobin A1c (HbA1c) values (<20 weeks). The incidence of prenatally diagnosed CHD was calculated and stratified by HbA1c level. Poor glycemic control was defined as an HbA1c level of 8.5 % or higher. Fetal echocardiography was used to identify fetuses that resulted in infants with suspected CHD. Neonatal echocardiograms and pathology reports were reviewed for confirmation of the diagnosis. Of 535 patients, 30 (5.6 %) delivered an infant with confirmed CHD. Among the patients with poor glycemic control, 8.3 % (n = 17) delivered an infant with CHD, whereas 3.9 % (n = 13) of those with an HbA1c level lower than 8.5 % delivered an infant with CHD (p = 0.03). Poor glycemic control in early pregnancy is associated with an increased risk of CHD in offspring. The incidence of CHD in patients with adequate glycemic control still is sufficiently high to justify routine fetal echocardiography for all gravidas with preexisting diabetes regardless of HbA1c level.

New concepts in diabetic embryopathy

Diabetes mellitus is responsible for nearly 10% of fetal anomalies in diabetic pregnancies. Although aggressive perinatal care and glycemic control are available in developed countries, the birth defect rate in diabetic pregnancies remains higher than that in the general population. Major cellular activities (ie, proliferation and apoptosis) and intracellular metabolic conditions (ie, nitrosative, oxidative, and endoplasmic reticulum stress) have been shown to be associated with diabetic embryopathy using animal models. Translating advances made in animal studies into clinical applications in humans requires collaborative efforts across the basic research, preclinical, and clinical communities.

Differences in pregnancy planning between women aged 18-44, with and without diabetes: behavioral risk factor surveillance system analysis

AIM

Assess differences in pregnancy planning and behavioral risk factors among women of reproductive age, by diabetes status.

METHODS

A secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance System (2002 and 2004) was conducted. Subjects were 18-44-year-old, non-pregnant, fertile women, grouped into two categories: non-diabetes (n=57,436), and diabetes (n=2929). Multivariable logistic regression was used to estimate adjusted prevalence odds ratios and 95% confidence intervals.

RESULTS

Approximately 93% of women of reproductive age with or without diabetes are not intending a pregnancy, and yet among them, women with diabetes are 22% more likely not to use any birth control at all. Women with diabetes are 3.4 times more likely to be obese, 1.4 times more likely to be overweight, 35% less likely to drink any alcohol, and 27% less likely to binge drink alcohol, than women without diabetes. There were no differences in risk factors between women with diabetes that were and were not intending a pregnancy.

CONCLUSIONS

Birth control nonuse for women with diabetes not intending a pregnancy and lack of behavioral change for women with diabetes intending a pregnancy, combined with an increasing prevalence in diabetes, will likely result in significant economic and social tolls on society.

Dietary glycemic index and the risk of birth defects

Prepregnancy diabetes and obesity have been identified as independent risk factors for several birth defects, providing support for a mechanism that involves hyperglycemia and hyperinsulinemia in the development of malformations. Data from the National Birth Defects Prevention Study from 1997 to 2007 were used to investigate the association between the maternal dietary glycemic index (DGI) and the risk of birth defects among nondiabetic women. DGI was categorized by using spline regression models and quartile distributions. Adjusted odds ratios and 95% confidence intervals were calculated. The joint effect of DGI and obesity was also examined. Among the 53 birth defects analyzed, high DGI, categorized by spline regression, was significantly associated with encephalocele (adjusted odds ratio (aOR) = 2.68), diaphragmatic hernia (aOR = 2.58), small intestinal atresia/stenosis (aOR = 2.97) including duodenal atresia/stenosis (aOR = 2.48), and atrial septal defect (aOR = 1.37). Using quartiles to categorize DGI, the authors identified associations with cleft lip with cleft palate (aOR = 1.23) and anorectal atresia/stenosis (aOR = 1.40). The joint effect of high DGI and obesity provided evidence of a synergistic effect on the risk of selected birth defects. High DGI is associated with an increased risk of a number of birth defects under study. Obesity coupled with high DGI appears to increase the risk further for some birth defects.

Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Pre-gestational diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. This systematic review was carried out to evaluate the effectiveness and safety of pre-pregnancy care in improving the rate of congenital malformations and perinatal mortality for women with pre-gestational diabetes mellitus.

METHODS

We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2011, without language restriction, for any pre-pregnancy care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women with type I or type II diabetes mellitus. Study design were trials (randomized and non-randomized), cohort and case-control studies.

RESULTS

Of the 2452 title scanned 54 full papers were retrieved of those 21 studies were included in this review. Twelve cohort studies at low and medium risk of bias, with 3088 women, were included in the meta-analysis. Meta-analysis suggested that pre-pregnancy care is effective in reducing congenital malformation, Risk Ratio (RR) 0.25 (95% CI 0.16-0.37), number needed to treat (NNT) 19 (95% CI 14-24), and perinatal mortality RR 0.34 (95% CI 0.15-0.75), NNT = 46 (95% CI 28-115). Pre-pregnancy care lowers glycosylated hemoglobin A1c (HbA1c) in the first trimester of pregnancy by an average of 1.92% (95% CI -2.05 to -1.79). However women who received pre-pregnancy care were at increased risk of hypoglycemia during the first trimester of pregnancy RR 1.51 (95% CI 1.15-1.99).

CONCLUSION

Pre-pregnancy care for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations, perinatal mortality and in reducing maternal HbA1C in the first trimester of pregnancy. Pre-pregnancy care might cause maternal hypoglycemia in the first trimester of pregnancy.

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

AIMS

Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

METHODS

Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17-40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

RESULTS

Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

CONCLUSIONS

Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care.

Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis

Background

Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus.

Methods

We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis.

Results

Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40).

Conclusion

Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy.

Maternal dietary glycemic intake and the risk of neural tube defects

Both maternal diabetes and obesity have been associated with an increased risk of neural tube defects (NTD), possibly due to a sustained state of hyperglycemia and/or hyperinsulinemia. Data were collected in the Boston University Slone Birth Defects Study (a case-control study) from 1988 to 1998. The authors examined whether high dietary glycemic index (DGI) and high dietary glycemic load (DGL) increased the risk of NTDs in nondiabetic women. Mothers of NTD cases and nonmalformed controls were interviewed in person within 6 months after delivery about diet and other exposures. Odds ratios and 95% confidence intervals were estimated from logistic regression for high DGI (> or =60) and high DGL (> or =205), with cutpoints determined by cubic spline. Of 698 case mothers, 25% had high DGI and 4% had high DGL. Of 696 control mothers, 15% had high DGI and 2% had high DGL. After adjustment for sociodemographic factors and other dietary factors, the odds ratio for high DGI was 1.5 (95% confidence interval: 1.1, 2.0); for high DGL, it was 1.8 (95% confidence interval: 0.8, 4.0). Diets with proportionally high DGI or DGL may put the developing fetus at risk of an NTD, adding further evidence that hyperglycemia lies within the pathogenic pathway.

Congenital heart disease in pregnancies complicated by maternal diabetes mellitus. An international clinical collaboration, literature review, and meta-analysis

PURPOSE

Investigation of the incidence and distribution of congenital structural cardiac malformations among the offspring of mothers with diabetes type 1 and of the influence of periconceptional glycemic control.

METHODS

Multicenter retrospective clinical study, literature review, and meta-analysis. The incidence and pattern of congenital heart disease in the own study population and in the literature on the offspring of type 1 diabetic mothers were compared with the incidence and spectrum of the various cardiovascular defects in the offspring of nondiabetic mothers as registered by EUROCAT Northern Netherlands. Medical records were, in addition, reviewed for HbA(1c) during the 1st trimester.

RESULTS

The distribution of congenital heart anomalies in the own diabetic study population was in accordance with the distribution encountered in the literature. This distribution differed considerably from that in the nondiabetic population. Approximately half the cardiovascular defects were conotruncal anomalies. The authors' study demonstrated a remarkable increase in the likelihood of visceral heterotaxia and variants of single ventricle among these patients. As expected, elevated HbA(1c) values during the 1st trimester were associated with offspring fetal cardiovascular defects.

CONCLUSION

This study shows an increased likelihood of specific heart anomalies, namely transposition of the great arteries, persistent truncus arteriosus, visceral heterotaxia and single ventricle, among offspring of diabetic mothers. This suggests a profound teratogenic effect at a very early stage in cardiogenesis. The study emphasizes the frequency with which the offspring of diabetes-complicated pregnancies suffer from complex forms of congenital heart disease. Pregnancies with poor 1st-trimester glycemic control are more prone to the presence of fetal heart disease.

Integrating educational and technological interventions to improve pregnancy outcomes in women with diabetes

A gap currently exists between our expectations of tight blood glucose control and the reality of safely achieving it before and during pregnancy. Technological and pharmaceutical advances will not in isolation prevent poor pregnancy outcomes without recognising the social, cultural and behavioural context of the women living with diabetes. Neither will behavioural and/or educational programmes completely overcome the fundamentally disordered metabolic pathways and physiological challenges of pregnancy. Improved integration of the technological, behavioural and educational aspects of diabetes care will pave the way for truly personalized, interdisciplinary diabetes management and ultimately improved pregnancy outcomes for women with diabetes and their infants.

A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy

OBJECTIVE

To describe perinatal outcomes of women with pregestational diabetes treated with short-acting, regular insulin and the short-acting insulin analogue, lispro.

STUDY DESIGN

This was a prospective observational study of women with pregestational diabetes maintained on short-acting insulin regimens over a 3-year period. Clinical characteristics, aspects of diabetic therapy, and perinatal/neonatal outcomes were collected.

RESULTS

Of 107 women, 49 were maintained on regular insulin and 58 utilized the insulin analogue, lispro. Frequency of type 1 diabetes, maternal age, overweight/obese pregravid body mass index (> or =25 kg/m2), preexisting hypertension, and presence of vascular disease were similar between groups. Women treated with lispro had a longer duration of diabetes (11.4 vs. 8.3 years, p = 0.04). Glycemic control was improved in women managed with lispro compared to regular insulin (HgbA1c 5.9 vs. 6.7, p = 0.009). Total insulin requirements were lower in the lispro group in the first (0.58 vs. 0.79 units/kg, p = 0.02), second (0.75 vs. 1.10 units/kg, p = 0.002), and third (0.98 vs. 1.25 units/kg, p = 0.03) trimesters of pregnancy. Mean infant birth weight was greater in the lispro group, whereas the rate of large for gestational age infants and ponderal indices were similar between groups. Malformation rate, gestational age at delivery, neonatal intensive care unit admission, neonatal length of stay, rates of respiratory distress syndrome, and hypoglycemia were similar.

CONCLUSIONS

Women treated with lispro demonstrated improved glycemic control and lower total insulin requirements during pregnancy compared to those receiving regular insulin. Perinatal outcomes were similar between women treated with both types of insulin.