"Diabetes Just Tends to Take Over Everything": Experiences of Support and Barriers to Diabetes Management for Pregnancy in Women With Type 1 Diabetes

Continuous glucose monitoring in pregnancies with type 1 diabetes: small increases in time-in-range improve maternal and perinatal outcomes

BACKGROUND

Continuous glucose monitors provide detailed information regarding glycemic control in pregnant patients with type 1 diabetes. Little data have been published examining the association between continuous glucose monitor parameters and perinatal outcomes among gravidas with type 1 diabetes using continuous glucose monitors.

OBJECTIVE

This study aimed to examine the association between perinatal outcomes and time-in-range as assessed by continuous glucose monitors used in pregnant individuals with type 1 diabetes. We hypothesized that higher time-in-range would be associated with lower risk of adverse perinatal outcomes.

STUDY DESIGN

This multicenter retrospective cohort study included all gravidas with type 1 diabetes using continuous glucose monitors who delivered from 2020 to 2022 at 5 University of California sites. Only those with continuous glucose monitor target range set to 70 to 140 mg/dL (±10 mg/dL) were included. Time-in-range (%) was recorded at 12, 16, 20, 24, 28, and 32 weeks. The primary maternal and neonatal outcomes were preeclampsia and large for gestational age, defined as birthweight ≥95th percentile. Kruskal-Wallis tests were used to compare median time-in-range between those with and without the primary outcomes. Log-binomial regression was used to obtain risk ratios, with adjustment for microvascular disease and years with type 1 diabetes.

RESULTS

A total of 91 patients were included. Most used an insulin pump (81%) and did not have diabetic microvascular disease (72%). Median time since diagnosis of type 1 diabetes was 16 years, and median periconception hemoglobin A1c was 6.7%. Compared with those with preeclampsia, normotensive gravidas had significantly higher time-in-range at nearly every time point. A similar pattern was observed for those with normal-birthweight infants compared with large-for-gestational-age infants. On adjusted analyses, every 5-unit increase in time-in-range at 12 weeks was associated with 45% and 46% reductions in the risks of preeclampsia and large for gestational age, respectively (preeclampsia: adjusted risk ratio, 0.55; 95% confidence interval, 0.30-0.99; large for gestational age: adjusted risk ratio, 0.54; 95% confidence interval, 0.29-0.99).

CONCLUSION

Higher time-in-range is associated with lower risk of preeclampsia and large for gestational age. This association is observed early in gestation, when each 5-unit increase in time-in-range is associated with ∼50% reduction in the risk of these complications. These findings can be used to counsel patients regarding the risk of pregnancy complications at specific time-in-range values, and to encourage patients that even small improvements in time-in-range can have significant impact on pregnancy outcomes. Larger studies are needed to further explore these findings and to identify optimal time-in-range to reduce perinatal complication rates.

The Examination and Exploration of Diabetes Distress in Pre-existing Diabetes in Pregnancy: A Mixed-methods Study

OBJECTIVES

Diabetes distress (DD) has been understudied in the pregnancy population. Pregnancy is known to be a complex, highly stressful time for women with diabetes because of medical risks and the high burden of diabetes management. Our aim in this study was to explain and understand DD in women with pre-existing diabetes in pregnancy.

METHODS

An explanatory, sequential mixed-methods study was undertaken. The first strand consisted of a cross-sectional study of 76 women with type 1 and type 2 diabetes. A nested sampling approach was used to re-recruit 18 women back into the second strand for qualitative interviews using an interpretive description approach.

RESULTS

DD was measured by the validated Problem Area in Diabetes (PAID) scale. A PAID score of ≥40 was positive for distress. DD prevalence was 22.4% in the cross-sectional cohort and the average PAID score was 27.75 (standard deviation 16.08). In the qualitative strand, women with a range of PAID scores (10.0 to 60.0) were sampled for interviews. The majority of these participants described themes of DD in their interviews. Of the 15 women who described DD thematically, only 6 had positive PAID scores.

CONCLUSIONS

Integration of the mixed-methods data underscores important meta-inferences about DD in pregnancy, namely that DD was present to a greater degree than the PAID tool is sensitive to. DD was present qualitatively in most of the qualitative sample, despite interviewing women with a range of PAID scores. Future research on a pregnancy-specific DD scale is needed.

Perceptions of diabetes distress during pregnancy in women with type 1 and type 2 diabetes: a qualitative interpretive description study

BACKGROUND

Diabetes distress is commonly seen in adults with pre-existing diabetes and is associated with worsened glycemic management and self-management practices. While a majority of women report increased stress during pregnancy, it is unknown how women with type 1 or type 2 diabetes experience diabetes distress during this unique and transitional time.

PURPOSE

This study aimed to understand the experiences and perceptions of diabetes distress in women with pre-existing diabetes during pregnancy.

METHODS

A qualitative study using an interpretive description approach was conducted. In-depth, one to one interviewing was used to capture rich descriptions of the pregnancy experience. Nested, stratified, and theoretical sampling was used to recruit 18 participants with type 1 and type 2 diabetes from the quantitative strand of this mixed methods study. Constant comparative analysis was used to inductively analyze the data and develop themes.

FINDINGS

Four themes, each with several subthemes, emerged under the main finding of "Diabetes Distress": 1) Worry for Baby's Health - "What's this going to do to the baby?"' 2) Feeling Overwhelmed with Diabetes Management-"It just seemed unattainable"; 3) Living with Diabetes - "There's no way out" and 4) Cycle of Diabetes Distress.

CONCLUSIONS

The findings from this study identify the sources and experiences of diabetes distress during pregnancy in women with pre-existing diabetes. Diabetes distress often presents as cyclical and multifaceted during pregnancy, with elements of fear for the unborn baby, difficulties with diabetes management, and having negative lived experiences of diabetes. Further work is needed to develop appropriate screening tools for pregnancy and interventions to mitigate diabetes distress. Diabetes educators are well-positioned provide emotional support and person-centred self-management education to individuals with diabetes.

What are the childbearing experiences of women with type 1 diabetes? A scoping review of qualitative literature

PROBLEM

Type 1 diabetes is associated with the risk of adverse outcomes for mother and baby.

BACKGROUND

How pregnant people adapt to the challenges of type 1 diabetes and engage with healthcare professionals can affect how likely they will be to maintain good glycaemic control. Therefore, it is important to understand the childbearing and care experiences of women with type 1 diabetes.

AIM

To examine contemporary literature describing the childbearing experiences of women with type 1 diabetes over the last decade.

METHOD

The review follows 5 stages of Arksey and O'Malley's scoping review framework. Four databases were searched for English language publications 2012-2023 using indexed terms and Boolean operators. 64 studies were retrieved, 10 included in the review. Braun and Clarke's thematic synthesis process was used to collate findings.

FINDINGS

Five key themes emerged: 1. Glycaemic control dominates the childbearing journey, 2. Emphasis on risk, 3. Importance of social and peer support, 4. Care organisation, systems, and communication, 5. The impact of technology on the childbearing experience.

CONCLUSION

Based on lived experiences, women with type 1 diabetes value being treated as partners in their care by health professionals providing medical and midwifery services. Peer and social support from family, friends and the diabetes community can bring comfort and reassurance in a perceived 'medicalised' childbearing journey. Further research is needed on the impact of the use of type 1 diabetes technologies on childbearing experiences and how peer support can be incorporated into current care provision.

Occupations and balance during the transition to motherhood with a lifetime chronic illness: A scoping review examining cystic fibrosis, asthma, and Type-1 diabetes

INTRODUCTION

Throughout the transition to motherhood, changes are experienced across a woman's physical, mental, social, and occupational self. Maternal chronic illness adds the complexity of increased healthcare needs and navigating a high-risk, medicalised pregnancy, birth, and post-natal period. Literature concerning motherhood transitions in chronic illness generally focusses on the mother's medical health and pregnancy outcomes; little is known about the impacts on women's occupations, balance, and quality of life. Understanding these issues may help support women in a more tailored and holistic way.

OBJECTIVE

This scoping review aims to gather, analyse, and synthesise existing empirical research on occupational engagement and occupational balance as they impact on wellbeing and quality of life in women with a lifetime chronic illness before and during pregnancy and in early motherhood.

METHOD

The review follows the nine-stage framework described in the Joanna Briggs Institute Manual for Evidence Synthesis (2020). Five databases were searched: Embase, Medline, PsycINFO, CINAHL, Scopus, and OT Seeker. Data were extracted and examined via content analysis, described in narrative synthesis, summarised into a conceptual framework, and tabulated.

FINDINGS

A total of 8,655 papers were discovered on initial search. Following title and abstract screening, 220 full-text studies were assessed for eligibility, and 46 papers were finally included. Analysis generated four major themes: The Disrupted Transition Journey; Adaptation, Compromise and Choice; Outcomes; and Drawing on What's Available. The themes were conceptualised into a framework to explain how women sought to balance motherhood and illness-related occupations. Adequate access to information, social support, expert care, and financial resources improved both quality of life and healthcare compliance.

CONCLUSION

Findings of this scoping review deepen the understanding of occupational balance during the transition to motherhood in the context of lifetime chronic illness. Healthcare providers and supportive family and friends can use this knowledge to adapt their approach to assisting women with chronic illness on the motherhood journey. These findings may also inform further inquiry into the scope of occupational therapy practice with this population.

Listening to Women: Experiences of Using Closed-Loop in Type 1 Diabetes Pregnancy

Introduction: Recent high-profile calls have emphasized that women's experiences should be considered in maternity care provisioning. We explored women's experiences of using closed-loop during type 1 diabetes (T1D) pregnancy to inform decision-making about antenatal rollout and guidance and support given to future users. Methods: We interviewed 23 closed-loop participants in the Automated insulin Delivery Among Pregnant women with T1D (AiDAPT) trial after randomization to closed-loop and ∼20 weeks later. Data were analyzed thematically. Results: Women described how closed-loop lessened the physical and mental demands of diabetes management, enabling them to feel more normal and sleep better. By virtue of spending increased time-in-range, women also worried less about risks to their baby and being judged negatively by health care professionals. Most noted that intensive input and support during early pregnancy had been crucial to adjusting to, and developing confidence in, the technology. Women emphasized that attaining pregnancy glucose targets still required ongoing effort from themselves and the health care team. Women described needing education to help them determine when, and how, to intervene and when to allow the closed-loop to operate without interference. All women reported more enjoyable pregnancy experiences as a result of using closed-loop; some also noted being able to remain longer in paid employment. Conclusions: Study findings endorse closed-loop use in T1D pregnancy by highlighting how the technology can facilitate positive pregnancy experiences. To realize fully the benefits of closed-loop, pregnant women would benefit from initial intensive oversight and support together with closed-loop specific education and training. Clinical Trial Registration number: NCT04938557.

Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets

Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.

High Risk-pregnant Women's Experiences of Risk Management: A Qualitative Study

Background

Maternal and fetal morbidity and mortality depend on identifying of pregnancy risks and risk management. There is a dearth of information about the experiences of high-risk pregnant mothers in self-mitigation of the risk in the socio-cultural setting of Iran. This research was conducted to explore the risk management experiences of high-risk pregnant mothers.

Methods

This Qualitative study was conducted in educational hospitals in Mashhad, Iran, from July 2018 to December 2020. The purposive sampling method was used to recruit the participants based on medical or obstetric high-risk conditions in pregnancy. Qualitative data were obtained from in-depth and semi-structured 29 interviews. Mothers' experiences of pregnancy in a risky condition were asked, and the interview continued until data saturation. Data were analyzed using the MAXQDA 10 software and the Elo and Kyngäs method.

Results

Maternal experiences for risk management in pregnancy were formed by nine sub-categories and three categories: the excitement of emotion including: "feeling worry and despair", "gladness in the shadow of hope and optimism", "momentary shocking and excitement", and "inactivity and helplessness"; self-contemplation including: "active analysis of the ways of moderating the risk", "cognitive denial", and "ignoring the risk"; and witnessed action including: "problem-focused and rational actions", and "avoidance and inefficient engagements".

Conclusion

Risk management experiences of pregnant women with high-risk pregnancies include a wide range of positive and negative feelings, effective and ineffective thoughts, and behaviors. Mutual collaboration between mothers and midwives/obstetricians by providing high-quality risk management counseling can lead to choosing effective risk management strategies.

Quality of patient-reported outcome reporting in trials of diabetes in pregnancy: A systematic review

AIMS

Patient-reported outcomes (PROs) are reports of the patient's health status that come directly from the patient without interpretation by the clinician or anyone else. They are increasingly used in randomised controlled trials (RCTs). In this systematic review we identified RCTs conducted in women with diabetes in pregnancy which included PROs in their primary or secondary outcomes. We then evaluated the quality of PRO reporting against an internationally accepted reporting framework (Consolidated Standards of Reporting Trials (CONSORT-PRO) guidelines).

METHODS

We searched online databases for studies published 2013-2021 using a combination of keywords. Two authors reviewed all abstracts independently. Data on study characteristics and the quality of PRO reporting were extracted from relevant studies. We conducted a multiple regression analysis to identify factors associated with high quality reporting.

RESULTS

We identified 7122 citations. Thirty-five articles were included for review. Only 17% of RCTs included a PRO as a primary or secondary outcome. Out of a maximum score of 100 the median score was 46, indicating sub-optimal reporting. A multiple regression analysis did not reveal any factors associated with high quality reporting.

CONCLUSIONS

Researchers should be mindful of the importance of PRO inclusion and reporting and include reliable PROs in trials.

Is self-management a burden? What are the experiences of women self-managing chronic conditions during pregnancy? A systematic review

OBJECTIVE

This systematic review examines the qualitative literature on women's experiences of self-managing chronic conditions in pregnancy.

DESIGN

Systematic review of qualitative literature. Searches were performed in PubMed and CINAHL from inception to February 2021. Critical interpretive synthesis informed the coding framework and the analysis of the data. The Burden of Treatment theory emerged during the initial analysis as having the most synergy with the included literature, themes were refined to consider key concepts from this theory.

PARTICIPANTS

Pregnant women who are self-managing a chronic condition.

RESULTS

A total of 2695 articles were screened and 25 were reviewed in detail. All 16 included studies concerned diabetes self-management in pregnancy. Common themes coalesced around motivations for, and barriers to, self-management. Women self-managed primarily for the health of their baby. Barriers identified were anxiety, lack of understanding and a lack of support from families and healthcare professionals.

CONCLUSIONS

Pregnant women have different motivating factors for self-management than the general population and further research on a range of self-management of chronic conditions in pregnancy is needed.

PROSPERO REGISTRATION NUMBER

CRD42019136681.

Perceptions of risk in pregnancy with chronic disease: A systematic review and thematic synthesis

BACKGROUND

Women with chronic disease are at increased risk of adverse pregnancy outcomes. Pregnancies which pose higher risk, often require increased medical supervision and intervention. How women perceive their pregnancy risk and its impact on health behaviour is poorly understood. The aim of this systematic review of qualitative literature is to evaluate risk perceptions of pregnancy in women with chronic disease.

METHODS

Eleven electronic databases including grey literature were systematically searched for qualitative studies published in English which reported on pregnancy, risk perception and chronic disease. Full texts were reviewed by two researchers, independently. Quality was assessed using the Critical Appraisal Skills Programme Qualitative checklist and data were synthesised using a thematic synthesis approach. The analysis used all text under the findings or results section from each included paper as data. The protocol was registered with PROSPERO.

RESULTS

Eight studies were included in the review. Three themes with sub-themes were constructed from the analysis including: Information Synthesis (Sub-themes: Risk to Self and Risk to Baby), Psychosocial Factors (Sub-themes: Emotional Response, Self-efficacy, Healthcare Relationship), and Impact on Behaviour (Sub-themes: Perceived Risk and Objective Risk). Themes fitted within an overarching concept of Balancing Act. The themes together inter-relate to understand how women with chronic disease perceive their risk in pregnancy.

CONCLUSIONS

Women's pregnancy-related behaviour and engagement with healthcare services appear to be influenced by their perception of pregnancy risk. Women with chronic disease have risk perceptions which are highly individualised. Assessment and communication of women's pregnancy risk should consider their own understanding and perception of risk. Different chronic diseases introduce diverse pregnancy risks and further research is needed to understand women's risk perceptions in specific chronic diseases.