Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2 =82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2 =82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2 =0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2 =0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2 =87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2 =0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

Dietary patterns during pregnancy and maternal and birth outcomes in women with type 1 diabetes: the Environmental Determinants of Islet Autoimmunity (ENDIA) study

AIMS/HYPOTHESIS

Dietary patterns characterised by high intakes of vegetables may lower the risk of pre-eclampsia and premature birth in the general population. The effect of dietary patterns in women with type 1 diabetes, who have an increased risk of complications in pregnancy, is not known. The aim of this study was to investigate the relationship between dietary patterns and physical activity during pregnancy and maternal complications and birth outcomes in women with type 1 diabetes. We also compared dietary patterns in women with and without type 1 diabetes.

METHODS

Diet was assessed in the third trimester using a validated food frequency questionnaire in participants followed prospectively in the multi-centre Environmental Determinants of Islet Autoimmunity (ENDIA) study. Dietary patterns were characterised by principal component analysis. The Pregnancy Physical Activity Questionnaire was completed in each trimester. Data for maternal and birth outcomes were collected prospectively.

RESULTS

Questionnaires were completed by 973 participants during 1124 pregnancies. Women with type 1 diabetes (n=615 pregnancies with dietary data) were more likely to have a 'fresh food' dietary pattern than women without type 1 diabetes (OR 1.19, 95% CI 1.07, 1.31; p=0.001). In women with type 1 diabetes, an increase equivalent to a change from quartile 1 to 3 in 'fresh food' dietary pattern score was associated with a lower risk of pre-eclampsia (OR 0.37, 95% CI 0.17, 0.78; p=0.01) and premature birth (OR 0.35, 95% CI 0.20, 0.62, p<0.001). These associations were mediated in part by BMI and HbA1c. The 'processed food' dietary pattern was associated with an increased birthweight (β coefficient 56.8 g, 95% CI 2.8, 110.8; p=0.04). Physical activity did not relate to outcomes.

CONCLUSIONS/INTERPRETATION

A dietary pattern higher in fresh foods during pregnancy was associated with sizeable reductions in risk of pre-eclampsia and premature birth in women with type 1 diabetes.

Associations of High BMI and Excessive Gestational Weight Gain With Pregnancy Outcomes in Women With Type 1 Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

The increased risk of pregnancy complications in type 1 diabetes is mainly attributed to maternal hyperglycemia. However, it is unclear whether other potentially modifiable factors also contribute to risk in this population.

PURPOSE

We sought to assess whether high BMI and excessive gestational weight gain (GWG) are associated with perinatal complications in type 1 diabetes.

DATA SOURCES

We searched Medline, Embase, PubMed, Scopus, Web of Science, and Cochrane databases to January 2024.

STUDY SELECTION

Studies examining associations between periconception BMI or GWG and perinatal complications in type 1 diabetes were included.

DATA EXTRACTION

We used a predesigned data extraction template to extract study data including year, country, sample size, participants' characteristics, exposure, and outcomes.

DATA SYNTHESIS

We included 29 studies (18,965 pregnancies; 1978-2019) in the meta-analysis. A 1 kg/m2/1 kg increase in preconception BMI or GWG was associated with a 3% and 11% increase, respectively, in perinatal complications (BMI odds ratio [OR] 1.03 [95% CI 1.01-1.06]; GWG OR 1.11 [95% CI 1.04-1.18]). Preconception BMI ≥ 25 kg/m2 or excessive GWG was associated with a 22% and 50% increase, respectively, in perinatal complications (BMI OR 1.22 [95% CI 1.11-1.34]; GWG OR 1.50 [95% CI 1.31-1.73]). BMI was associated with congenital malformation, preeclampsia, and neonatal intensive care unit admission. Excessive GWG was associated with preeclampsia, cesarean delivery, large for gestational age, and macrosomia.

LIMITATIONS

Limitations included retrospective study design, variable measurement for exposures and outcomes, small number of studies for some outcomes, and no data from Asia and Africa.

CONCLUSIONS

Addressing maternal BMI prepregnancy and preventing excessive GWG should be key clinical priorities to improve outcomes in pregnant women with type 1 diabetes.

Continuous glucose monitoring vs. self-monitoring in pregnant individuals with type 1 diabetes: an economic analysis

BACKGROUND

In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy.

OBJECTIVE

To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus.

STUDY DESIGN

We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations.

RESULTS

In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15.

CONCLUSION

Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.

Environmental Determinants of Islet Autoimmunity (ENDIA) longitudinal prospective pregnancy to childhood cohort study of Australian children at risk of type 1 diabetes: parental demographics and birth information

INTRODUCTION

The Environmental Determinants of Islet Autoimmunity (ENDIA) Study is an ongoing Australian prospective cohort study investigating how modifiable prenatal and early-life exposures drive the development of islet autoimmunity and type 1 diabetes (T1D) in children. In this profile, we describe the cohort's parental demographics, maternal and neonatal outcomes and human leukocyte antigen (HLA) genotypes.

RESEARCH DESIGN AND METHODS

Inclusion criteria were an unborn child, or infant aged less than 6 months, with a first-degree relative (FDR) with T1D. The primary outcome was persistent islet autoimmunity, with children followed until a T1D diagnosis or 10 years of age. Demographic data were collected at enrollment. Lifestyle, clinical and anthropometric data were collected at each visit during pregnancy and clinical pregnancy and birth data were verified against medical case notes. Data were compared between mothers with and without T1D. HLA genotyping was performed on the ENDIA child and all available FDRs.

RESULTS

The final cohort comprised 1473 infants born to 1214 gestational mothers across 1453 pregnancies, with 80% enrolled during pregnancy. The distribution of familial T1D probands was 62% maternal, 28% paternal and 11% sibling. The frequency of high-risk HLA genotypes was highest in T1D probands, followed by ENDIA infants, and lowest among unaffected family members. Mothers with T1D had higher rates of pregnancy complications and perinatal intervention, and larger babies of shorter gestation. Parent demographics were comparable to the Australian population for age, parity and obesity. A greater percentage of ENDIA parents were Australian born, lived in a major city and had higher socioeconomic advantage and education.

CONCLUSIONS

This comprehensive profile provides the context for understanding ENDIA's scope, methodology, unique strengths and limitations. Now fully recruited, ENDIA will provide unique insights into the roles of early-life factors in the development of islet autoimmunity and T1D in the Australian environment.

TRIAL REGISTRATION NUMBER

ACTRN12613000794707.

Normal Ovarian Function in Subfertile Mouse with Amhr2-Cre-Driven Ablation of Insr and Igf1r

Insulin receptor signaling promotes cell differentiation, proliferation, and growth which are essential for oocyte maturation, embryo implantation, endometrial decidualization, and placentation. The dysregulation of insulin signaling in women with metabolic syndromes including diabetes exhibits poor pregnancy outcomes that are poorly understood. We utilized the Cre/LoxP system to target the tissue-specific conditional ablation of insulin receptor (Insr) and insulin-like growth factor-1 receptor (Igf1r) using an anti-Mullerian hormone receptor 2 (Amhr2) Cre-driver which is active in ovarian granulosa and uterine stromal cells. Our long-term goal is to examine insulin-dependent molecular mechanisms that underlie diabetic pregnancy complications, and our conditional knockout models allow for such investigation without confounding effects of ligand identity, source and cross-reactivity, or global metabolic status within dams. Puberty occurred with normal timing in all conditional knockout models. Estrous cycles progressed normally in Insrd/d females but were briefly stalled in diestrus in Igf1rd/d and double receptor (DKO) mice. The expression of vital ovulatory genes (Lhcgr, Pgr, Ptgs2) was not significantly different in 12 h post-hCG superovulated ovaries in knockout mice. Antral follicles exhibited an elevated apoptosis of granulosa cells in Igf1rd/d and DKO mice. However, the distribution of ovarian follicle subtypes and subsequent ovulations was normal in all insulin receptor mutants compared to littermate controls. While ovulation was normal, all knockout lines were subfertile suggesting that the loss of insulin receptor signaling in the uterine stroma elicits implantation and decidualization defects responsible for subfertility in Amhr2-Cre-derived insulin receptor mutants.

Pregnant women with diabetes and their clinician's experience of participating in a pilot randomised controlled trial of corticosteroid administration in late pregnancy: A qualitative study

BACKGROUND

Little research exists to support the administration of corticosteroids to pregnant women with diabetes. Pregnant women are often excluded from clinical trials due to concerns of harm to the foetus.

AIM

This study aimed to understand the experiences of women and clinicians of participating in the Prevention of neonatal Respiratory distress with antenatal corticosteroids before Elective Caesarean section in women with Diabetes pilot randomised controlled trial to determine the acceptability of the study protocol.

METHODS

Women and clinicians participating in the pilot trial were invited to complete a telephone interview regarding their experiences of participating. Qualitative data were collected and subsequently analysed using thematic analysis.

RESULTS

A total of 13 women and nine clinicians were recruited between June 2020 and May 2022 for a telephone interview. Participating in the study was deemed acceptable by women and clinicians. Women chose to participate in the study due to the perceived low risk of harm associated with the intervention and for altruistic reasons. The high level of clinical support and information provided for the duration of the pilot trial was valued by women and clinicians. All clinicians highlighted the importance of conducting the trial to inform evidence-based practice.

CONCLUSIONS

Pregnant women are more likely to participate in clinical trials when perceived risks are low and they are well-informed during decision-making. Clinicians will support clinical trials when they perceive a benefit to practice and feel assured that women receive extensive monitoring and support. Incorporating these factors into study protocols is more likely to be successful in recruiting pregnant women and maintaining the engagement of clinical staff for the duration of clinical trials.

PATIENT OR PUBLIC CONTRIBUTIONS

Patients were invited to be participants in this study. A consumer has been included in the planning and oversite of the large multicentre trial.

PRECeDe Pilot: Prevention of neonatal respiratory distress with antenatal corticosteroids before elective caesarean section in women with diabetes - a feasibility randomised trial

OBJECTIVE

The PRECeDe Pilot Trial was designed to determine the feasibility of undertaking a multicentre, randomised controlled trial (RCT) to assess the efficacy of antenatal corticosteroids administration within 7 days before elective caesarean section (CS) in women with pre-gestational diabetes (PGDM) or gestational diabetes (GDM).

DESIGN

Triple blind, parallel group, placebo-controlled, pilot RCT.

SETTING

Single-centre tertiary maternity hospital in Melbourne, Australia.

POPULATION

Pregnant women with PGDM (type 1 or type 2 diabetes) or GDM booked for a planned CS scheduled between 35+0 and 38+6  weeks of gestation.

METHODS

Eligible participants were randomised to receive two injections of either betamethasone 11.4 mg or normal saline placebo, 24 hours apart within 7 days before CS scheduled between 35+0 and 38+6  weeks of gestation.

MAIN OUTCOME MEASURE

The proportion of eligible women who consented and were randomised.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12619001475134.

RESULTS

Of 537 women eligible, 182 were approached and 47 (26%) were recruited. Of these, 22 were allocated to the betamethasone group and 25 were allocated to the placebo group. There were no serious adverse events related to participation.

CONCLUSION

It is feasible to undertake a triple-blind, placebo-controlled RCT investigating the efficacy of antenatal corticosteroids in preventing respiratory morbidity in infants of women with PGDM or GDM who are undergoing an elective CS between 35+0 and 38+6  weeks.

The effect of time interval between antenatal corticosteroid administration and delivery on outcomes in late preterm neonates born to mothers with diabetes: a retrospective cohort study

Objectives

The study aims to investigate whether the time interval between administering antenatal corticosteroids (ACS) and delivery influences the neonatal outcomes in late preterm (LPT) neonates (34 + 0 to 36 + 6 weeks) born to mothers with diabetes.

Study design

This retrospective cohort study included women with any type of diabetes who gave birth between 34 + 0 weeks and 36 + 6 weeks of gestation. Based on the time interval between the first dose of corticosteroid and delivery, the cases were stratified into the following groups: <2, 2-7, and >7 days. Women unexposed to ACS served as the control group. The primary outcomes included the incidence of neonatal hypoglycemia and respiratory distress syndrome/transient tachypnea of the newborn. Multivariate logistic regression was used to assess the relationship between the time interval and neonatal outcomes and adjust for potential confounders.

Results

The study enrolled a total of 636 parturients. Among them, 247 (38.8%) delivered within 2 days after ACS administration, 169 (26.6%) within 2-7 days, and 126 (19.8%) at >7 days. Baseline characteristics such as type of diabetes, methods of glycemic control, preterm premature rupture of membrane, placenta previa, cesarean delivery, indication for delivery, percentage of large for gestational age, birth weight, and HbA1c in the second or third trimester were significantly different among the four groups. The multivariate analysis showed no statistically significant difference in the incidence of primary or secondary neonatal outcomes between the case and control groups.

Conclusions

ACS treatment was not associated with neonatal hypoglycemia and respiratory outcomes in LPT neonates born to diabetic mothers, regardless of the time interval to delivery.

Double diabetes as an effect modifier for adverse perinatal outcome in pregnant women with type 1 diabetes mellitus - a retrospective multicenter cohort study

Introduction

Double diabetes (DDiab) is defined as T1DM coexisting with insulin resistance (IR), metabolic syndrome (MetS), and/or obesity. Little evidence is available regarding how frequent DDiab is among T1DM pregnancies and whether it affects the perinatal outcome in this population.

Aims of the study

To explore the prevalence of DDiab in early pregnancy in the cohort of pregnant women with T1DM and to examine the association between an early-pregnancy DDiab status and fetomaternal complications characteristic for T1DM in pregnancy.

Material and methods

A retrospective data analysis of the multicenter cohort of N=495 pregnant women in singleton pregnancy complicated with T1DM followed from early pregnancy until delivery in three tertiary referral centers. DDiab status was defined as T1DM plus pre-pregnancy obesity defined as BMI≥30 kg/m2 measured at the first antenatal visit (DDiabOb), or T1DM plus pre-pregnancy IR defined as eGDR (estimated Glucose Disposal Rate) below the 25th centile for the cohort measured at the first antenatal visit (DDiabIR). Proportions of the adverse pregnancy outcomes were compared between DDiabOb and Non-DDiabOb and between DDiabIR and Non-DDiabIR patients.

Characteristics of the study group

(data presented as mean(SD) or percentage): age: 30.0(5.1) years; age when T1DM diagnosed: 17.5(8.5) years; T1DM duration: 12.0(7,9) years; microvascular complications (White classes R,F,RF): 11.9%, pre-pregnancy counselling: 26.6%, baseline gestational age: 10.5(4.3) weeks, pre-pregnancy BMI: 23.7(4.3) kg/m2; chronic hypertension: 9.1%, gestational hypertension (PIH) 10.7%, preeclampsia (PET): 3.2%; nulliparity 53.8%, smoking in pregnancy: 4.8%, eGWG: 22.4%, DDiabOB: 10.1%; DdiabIR: 25.2%; LGA: 44.0%, and NICU admission: 20.8%.

Results

(data from the univariate analysis given as OR(95%CI)): both DDiabOB and DDiabIR status increased the risk for eGWG [23.15 (10.82; 55.59); 3.03 (1.80; 5.08), respectively]. DDiabIR status increased the risk for PET [4.79 (1.68;14.6)], preterm delivery [1.84 (1.13; 3.21)], congenital malformation [2.15 (1.07;4.25)], and NICU hospitalization [2.2 (1.20;4.01)]. Both DDiabOB and DDiabIR accurately ruled out PET (NPV 97.3%/98.3%, accuracy: 88.3%/75.6%, respectively), congenital malformation (NPV 85.6%/88.4%, accuracy: 78.9/69.8, respectively), and perinatal mortality (NPV 98.7%/99.2%, accuracy: 88.8%/74.5%, respectively).

Conclusions

Double diabetes became a frequent complication in T1DM pregnant population. Double diabetes diagnosed in early pregnancy allows for further stratification of the T1DM pregnant population for additional maternal risk.

Neonatal outcomes following antenatal corticosteroid administration prior to elective caesarean delivery in women with pre-gestational diabetes: A retrospective cohort study

BACKGROUND

The benefit of antenatal corticosteroid (ACS) administration for the prevention of neonatal morbidity and mortality has been well described for preterm infants. Some studies have demonstrated a benefit for infants born by elective caesarean section (CS) at late preterm or term gestations. However, the neonatal benefits of ACS are not well described when given to pregnant women with diabetes.

AIMS

The aim of this study was to evaluate the neonatal outcomes following ACS administration in women with pre-gestational diabetes mellitus (PGDM) when administered prior to elective CS after 36 weeks gestation.

METHODS

This retrospective observational study included all women with PGDM who gave birth by elective CS between 36⁺⁰ and 38⁺⁶ weeks gestation. Neonatal outcomes for exposed participants were compared to outcomes for non-exposed participants.

RESULTS

Of the 306 women identified, 65 (21.2%) were exposed to ACS within seven days prior to birth and 241 (78.8%) were not. Although not statistically significant, ACS-exposed infants born prior to 38⁺⁰ weeks were less likely to require respiratory support or neonatal nursery admission compared to those who were not exposed; however, exposed infants born after 37⁺⁰ weeks were more likely to require parenteral treatment for neonatal hypoglycaemia.

CONCLUSION

This study did not demonstrate any statistically significant beneficial or harmful effects of ACS in neonates of women with PGDM who are born by elective CS. While it is plausible that ACS could reduce neonatal respiratory morbidity in this population, further prospective studies evaluating the benefits and harms are required before recommending this practice.

Precision medicine in type 1 diabetes

First envisioned by early diabetes clinicians, a person-centred approach to care was an aspirational goal that aimed to match insulin therapy to each individual's unique requirements. In the 100 years since the discovery of insulin, this goal has evolved to include personalised approaches to type 1 diabetes diagnosis, treatment, prevention and prediction. These advances have been facilitated by the recognition of type 1 diabetes as an autoimmune disease and by advances in our understanding of diabetes pathophysiology, genetics and natural history, which have occurred in parallel with advancements in insulin delivery, glucose monitoring and tools for self-management. In this review, we discuss how these personalised approaches have improved diabetes care and how improved understanding of pathogenesis and human biology might inform precision medicine in the future.

Glycemic Variability in Type 1 Diabetes Mellitus Pregnancies—Novel Parameters in Predicting Large-for-Gestational-Age Neonates: A Prospective Cohort Study

Pregnancies with type 1 diabetes mellitus (T1DM) have a high incidence of large-for-gestational-age neonates (LGA) despite optimal glycemic control. In recent years, glycemic variability (GV) has emerged as a possible risk factor for LGA, but the results of the conducted studies are unclear. This study analyzed the association between GV and LGA development in pregnancies with T1DM. This was a prospective cohort study of patients with T1DM who used continuous glucose monitoring (CGM) during pregnancy. Patients were followed from the first trimester to birth. GV parameters were calculated for every trimester using the EasyGV calculator. The main outcomes were LGA or no-LGA. Logistic regression analysis was used to assess the association between GV parameters and LGA. In total, 66 patients were included. The incidence of LGA was 36%. The analysis extracted several GV parameters that were significantly associated with the risk of LGA. The J-index was the only significant parameter in every trimester of pregnancy (odds ratios with confidence intervals were 1.33 (1.02, 1.73), 3.18 (1.12, 9.07), and 1.37 (1.03, 1.82), respectively. Increased GV is a risk factor for development of LGA. The J-index is a possible novel GV parameter that may be assessed in all three trimesters of pregnancy together with glycated hemoglobin and time-in-range.

Accuracy of Fetal Biacromial Diameter and Derived Ultrasonographic Parameters to Predict Shoulder Dystocia: A Prospective Observational Study

Background and Objectives: Shoulder dystocia (ShD) is one of most dangerous obstetric complication. The objective of this study was to determine if the ultrasonographic fetal biacromial diameter (BA) and derived parameters could predict ShD in uncomplicated term pregnancies. Materials and Methods: We conducted a prospective observational study in a tertiary care university hospital from March 2021 to February 2022. We included all full-term pregnancies accepted for delivery that received an accurate ultrasonography (USG) scan before delivery. USG biometry and estimated fetal weight (EFW) were collected. Therefore, we evaluated the diameter of the mid-arm, the transverse thoracic diameter (TTD) and the biacromial diameter (BA). BA was estimated using Youssef’s formula: TTD + 2 mid-arm diameters. The primary outcome was the evaluation of BA and its related parameters (BA/biparietal diameter (BPD), BA/head circumference (HC) and BA–BPD in fetuses with ShD versus fetuses without ShD. Diagnostic accuracy for ShD of BA, BA/BPD, BA/HC and BA–BPD was evaluated using receiver operator curve (ROC) analysis. Results: 90 women were included in the analysis, four of these had ShD and required extra maneuvers after head delivery. BA was increased in fetuses with ShD (150.4 cm; 95% CI 133.2 cm to 167.6 cm) compared to no-ShD (133.5 cm; 95% CI 130.1 cm to 137.0 cm; p = 0.04). Significant differences were also found between ShD and no-ShD groups for BA/BPD (1.66 (95% CI 1.46 to 1.86) vs. 1.44 (95% CI 1.41 to 1.48); p = 0.04), BA/HC (0.45 (95% CI 0.40 to 0.49) vs. 0.39 (95% CI 0.38 to 0.40); p = 0.01), BA–BPD (60.0 mm (95% CI 42.4 to 77.6 cm) vs. 41.4 (95% CI 38.2 to 44.6); p = 0.03), respectively. ROC analysis showed an overall good accuracy for ShD, with an AUC of 0.821 (p = 0.001) for BA alone and 0.881 (p = 0.001), 0.857 (p = 0.016) and 0.867 (p = 0.013) for BA/BPD, BA–BPD and BA/HC, respectively. Conclusions: BA alone, as well as BA/BPD, BA/HC and BA–BPD might be useful predictors of ShD in uncomplicated term pregnancies. However, such evidence needs extensive confirmation by means of additional studies with large sample sizes, especially in case of pregnancies at high risk for ShD (i.e., gestational diabetes).

Association Between HbA1c Levels on Adverse Pregnancy Outcomes During Pregnancy in Patients With Type 1 Diabetes

CONTEXT

Despite optimization of metabolic balance during pregnancy in type 1 diabetes (T1D), maternal-fetal complications remain higher than in the background population.

OBJECTIVE

We examined whether there is an association between glycated hemoglobin (HbA1c) levels and these complications.

METHODS

Retrospective study of pregnancies in 678 T1D subjects at Lille Hospital (1997-2019). The association between variations in HbA1c levels and complications was examined. The composite criterion (CC) was defined as having at least 1 of the following complications: prematurity, pre-eclampsia, large for gestational age (LGA), small for gestational age (SGA), or cesarean section.

RESULTS

Among the 678 births, median preconception HbA1c was 7.2% (55 mmol/mol), 361 were LGA (56%), 29 were SGA (4.5%), and 504 were births without preterm delivery (76.1%). The CC occurred in 81.8%. Higher HbA1c during the first trimester was associated with the CC (OR 1.04; 95% CI 1.02-1.06 per 0.1% increase; P < .001). Higher HbA1c during the third trimester was associated with the CC (OR 1.07; 95% CI 1.03-1.10 per 0.1% increase; P < .001). The group defined by a first trimester Hba1c >6.5% (48 mmol/mol) and a third trimester HbA1c <6% was associated with an increased rate of the CC (OR 2.81; 95% CI 1.01-7.86) and an increased rate of LGA (OR 2.20; 95% CI 1.01- 4.78).

CONCLUSION

Elevated HbA1c is associated with maternal-fetal complications. Despite optimization of metabolic balance during the third trimester, for patients with early glycemic imbalance the risk of LGA persists.

The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycaemia, behavioural considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that healthcare professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors. Graphical abstract.

The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycemia, behavioral considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management, and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that health care professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors.

Continuous Glucose Monitoring Time-in-Range and HbA1c Targets in Pregnant Women with Type 1 Diabetes

The CONCEPTT trial compared real-time Continuous Glucose Monitoring (RT-CGM) to capillary glucose monitoring in pregnant women with type 1 diabetes. We analyzed CGM and glycated hemoglobin (HbA_1c) measures in first (n = 221), second (n = 197), and third (n = 172) trimesters, aiming to examine target glucose attainment and associations with pregnancy outcomes. CGM targets were Time-in-range (TIR) > 70%, Time-above-range (TAR) <25%, and Time-below-range (TBR) < 4%, and HbA_1c targets < 6.5% (National Institute for Health and Care Excellence [NICE]) and HbA_1c < 6.0% in second and third trimesters (American Diabetes Association [ADA]). TIR/TAR/TBR targets were achieved by 7.7/14.5/30.3% participants in first, 10.2/14.2/52.8% in second, and 35.5/37.2/52.9% in third trimesters. CGM target attainment was low but increased during pregnancy and with RT-CGM use. In the adjusted analyses, achieving TBR target was associated with a higher risk of pre-eclampsia and neonatal hypoglycemia. ADA HbA_1c target attainment was low and unchanged during pregnancy (23.5/27.9/23.8%) but increased with RT-CGM use. In the adjusted analyses, HbA_1c target attainment was associated with a lower risk of preterm birth, large-for-gestational age and neonatal hypoglycemia. We conclude that CONCEPTT trial participants had a low rate of CGM and of HbA_1c target attainment. Attainment of CGM and NICE HbA_1c targets increased throughout gestation and all targets (both NICE/ADA HbA_1c and CGM) were more likely to be achieved by RT-CGM users, at 34 weeks' gestation. ADA HbA_1c target achievement was independently associated with better perinatal outcomes, while the independent association of TBR target achievement with increased risk warrants further study. ClinicalTrials.gov Registration Identifier NCT01788527.

Risk factors for pregnancy outcomes in Type 1 and Type 2 diabetes

BACKGROUND

Understanding the risk factors and pregnancy outcomes in women affected by Type 1 and Type 2 diabetes is important for pre-pregnancy counselling.

AIM

To explore differences in pregnancy outcomes between women with Type 1 and Type 2 diabetes, and healthy controls, and to examine the relationships between potential adverse risk factors and pregnancy outcomes in this cohort of women.

METHODS

This is a 10-year retrospective study of women with Type 1 diabetes (n = 92), Type 2 diabetes (n = 106) and healthy women without diabetes (controls) (n = 119) from a tertiary obstetric centre. Clinical and biochemical characteristics of women with Type 1 and Type 2 diabetes were determined and related to major obstetric outcomes using univariate analysis.

RESULTS

Women with pre-existing diabetes had higher adverse pregnancy outcomes (preeclampsia, emergency caesarean section, preterm birth <32 and 37 weeks, large for gestational age, neonatal jaundice, Apgar score < 7 at 5 min, neonatal intensive care admission and neonatal hypoglycaemia) compared to controls. A higher birth weight gestational centile (97.4% vs 72.4%, P = 0.001) and large for gestational age rate (63.4% vs 35.8%, P = 0.001) were observed in Type 1 diabetes compared to Type 2 diabetes. There were no differences in other outcomes between women with Type 1 and 2 diabetes.

CONCLUSION

In this exploratory study, risk factors for maternal adverse outcomes differ between Type 1 and Type 2 diabetes. Maternal and foetal adverse outcomes were higher in pregnancies affected by diabetes compared to healthy women but occurred with similar frequency in women with Type 1 and Type 2 diabetes.

Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms

Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.

Preeclampsia and other pregnancy outcomes in nulliparous women with type 1 diabetes: a retrospective survey

Obstetric complications are more common in women with diabetes than in the general population. This study aimed to learn about the first pregnancy of women with type 1 diabetes from the perspective of women from T1D Exchange-Glu and the T1D Exchange Clinic Registry. Participants were ≥18, diagnosed with type 1 diabetes before conception, and either currently pregnant or had given birth in the preceding 10 years. The final sample size was 533 women. Women who planned pregnancy had significantly lower HbA1c (A1c) at conception. Women who had higher A1cs at conception were at a higher risk for cesarean birth, increased weight gain, hypoglycemia during pregnancy, and earlier onset of preeclampsia. Overall 29% of women developed preeclampsia in this population, over seven times the rate in the general population. This study helps to expand our knowledge of women with type 1 diabetes during the perinatal period. Planning pregnancy, expanding education and support, and preventing preeclampsia may help to improve pregnancy outcomes.

Perinatal outcomes in pregnancies complicated by type 1 diabetes mellitus

The aim of this study was to explore the risk of perinatal outcomes in pre-gestational type 1 diabetes mellitus (T1DM) compared to gestational diabetes mellitus (GDM) and pregnancy without diabetes and to examine the association of glycemic level of third-trimester gestation with perinatal outcomes in T1DM. We included 69 pre-gestational T1DM, 1398 cases of GDM, and 1304 control pregnancies and collected data regarding demographics, obstetric, and perinatal outcomes from the hospital discharge database. Relative to the pregnancies without diabetes, women with T1DM encountered increasing risk of polyhydramnios, preterm delivery, and cesarean section. These adverse outcomes were also common in GDM, although with relatively lower adjusted ORs. The weights of babies delivered by women with T1DM were more intend to be large for gestational age, as well as to be less than 2.5 kg relative to those without diabetes. Poorly controlled hemoglobin A1c in late pregnancy was significantly associated with an increased risk of preterm birth in T1DM (adjusted odds ratio 2.01, 95%confidence interval 1.1-3.6). Women with T1DM have considerably increased risks of adverse perinatal outcomes, which appear more prevalent than the perinatal outcomes in women with GDM. Thus, a specific routine is required for pregnancy in T1DM to improve the glycemic control and obstetric care.

Studying the Effect of Maternal Pregestational Diabetes on Fetal Neurodevelopment Using Magnetoencephalography

Background. Developmental origin of health and disease states that an adverse intrauterine environment can lead to different diseases in later life. In this study, we aimed to explore the effect of maternal pregestational diabetes on the fetal brain activity using magnetoencephalography (MEG). Methods. Forty participants were included in an observational study with 9 type 1 and 19 type 2 diabetic pregnant women compared with data from 12 nondiabetic participants. Spontaneous fetal MEG signals were recorded and power spectral density was computed in 4 standard frequency bands. Group differences were investigated using analysis of covariance. Results. Our results showed that type 1 group was significantly different (P < .05) from the reference group for 3 of the 4 brain activity frequency bands, while in type 2 group, 2 bands exhibited this trend. When dichotomized based on the maternal glycemic control, significant differences in all bands were observed between the poor-control and reference groups. Conclusion. The fetal background brain activity parameters appear to be altered in diabetic pregnancy in comparison with the reference low-risk group. The study showed that maternal pregestational diabetes could potentially influence in utero neurodevelopment.

Pregnancy outcomes in women with onset of type 1 diabetes mellitus less than 18 years of age

BACKGROUND

Pregnancy in women with type 1 diabetes mellitus (T1DM) is associated with an increased risk of congenital malformations, obstetric complications and neonatal morbidity. This study aims to investigate maternal, perinatal and neonatal outcomes of pregnancies in women with onset of T1DM less than 18 years of age.

METHODS

This retrospective cohort study extracted data regarding prenatal, intrapartum and postnatal outcomes of pregnancies in women with onset of T1DM<18 years identified from the diabetes in pregnancy register at University Maternity Hospital Limerick, treated from July 1, 2007 to July 1, 2017.

RESULTS

Seventeen women with onset of T1DM <18 years gave birth to 23 live infants during the period studied. 73.9% of pregnancies were unplanned. Only 21.7% of pregnancies took preconceptual folic acid. 60.9% of infants required treatment for hypoglycemia.

CONCLUSION

The high prevalence of unplanned pregnancy and poor uptake of prepregnancy care must be improved on in order to improve outcomes for this high-risk group.

Controversies in antenatal corticosteroid treatment

Antenatal corticosteroids are now established as one of the cornerstones of therapy in the prevention of neonatal morbidity and mortality prior to preterm birth. Although this practice is widely accepted, a significant number of controversies exist. This review explores the knowledge gaps regarding the use of antenatal corticosteroids in the preterm, late preterm and term populations. Furthermore, the role of antenatal corticosteroids in special populations, such as diabetes, multiple pregnancies and periviable gestations, where high-quality data from randomized controlled trials are lacking, is also considered.

Case series of a hybrid closed-loop system used in pregnancies in clinical practice

BACKGROUND

Hybrid closed-loop (HCL) therapy is rarely studied in pregnancy. We present three cases of women with type 1 diabetes who used the Medtronic 670G HCL system for most or all of gestation.

METHODS

The Medtronic 670G system has a manual mode (no automated insulin delivery) and an auto mode (AM, HCL therapy). Women in this case series used AM off-label in gestation.

RESULTS

Case 1 started HCL therapy in the second trimester, her sensor glucose time spent <3.9 and >10 mmol/L improved thereafter. Case 1 had average sensor glucose (ASG) levels of 6.4 ± 2.4 mmol/L in the first trimester, 7.0 ± 2.7 mmol/L in the second trimester before HCL use, 7.1 ± 2.1 mmol/L in the second trimester after HCL use, and 6.8 ± 1.9 mmol/L in the third trimester. Case 1 continued AM during operative delivery and post-partum. Cases 2 and 3 used HCL therapy throughout gestation but with inconsistent time in AM. When they increased time in AM their glycaemic indices improved. Case 2 had ASG of 9.5 ± 3.4, 8.6 ± 2.9, and 7.9 ± 2.5 mmol/L in the first through third trimesters, respectively. Case 3 had ASG of 11.1 ± 4.8 and 3.9 to 10 mmol/L in the first and second trimesters, respectively. Case 2 continued HCL therapy post-partum, Case 3 did not.

CONCLUSIONS

CareLink® Clinical Software only reports the non-pregnant time in range. Nonetheless, this represents the first report of HCL therapy in pregnancy with a system approved by the Food and Drug Administration in non-pregnant populations.

Diabetes: a metabolic and reproductive disorder in women

Reproductive dysfunction is a common but little studied complication of diabetes. The spectrum of reproductive health problems in diabetes is broad, and encompasses delayed puberty and menarche, menstrual cycle abnormalities, subfertility, adverse pregnancy outcomes, and potentially early menopause. Depending on the age at diagnosis of diabetes, reproductive problems can manifest early on in puberty, emerge later when fertility is desired, or occur during the climacteric period. Historically, women with type 1 diabetes have frequently had amenorrhoea and infertility, due to central hypogonadism. With the intensification of insulin therapy and improved metabolic control, these problems have declined, but do persist. Additional reproductive implications of contemporary diabetes management are now emerging, including polycystic ovary syndrome and hyperandrogenism, which are underpinned by insulin action on the ovary. The sharp rise in type 2 diabetes incidence in youth suggests that more women of reproductive age will encounter diabetes-related reproductive problems in their lifetimes. With an ever increasing number of young women living with diabetes, clinicians need to be aware of and equipped for the challenges of navigating reproductive health concerns across the lifespan.

Ethnic differences in prevalence, risk factors, and perinatal outcomes of gestational diabetes mellitus: A comparison between immigrant ethnic Chinese women and Australian-born Caucasian women in Australia

BACKGROUND

The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. Ethnic differences in risk factors and perinatal outcomes are clinically important. Chinese women constitute approximately 10% of the world's population, and are an increasing migrant population, yet prevalence, risk factors, and outcomes of GDM in this population are insufficiently explored.

METHODS

A retrospective study of a large pregnancy dataset comparing GDM prevalence, risk factors, and perinatal outcomes between immigrant ethnic Chinese women and Australian-born Caucasian women was conducted using logistic regression.

RESULTS

Overall, 73 517 births were extracted from the pregnancy databases of two of Australia's largest maternity services. Chinese women (n = 3419) had a 4-fold higher risk of GDM than Caucasians (n = 28 594) after adjusting for risk factors of GDM. A past history of GDM (adjusted odds ratio [aOR] 5.24; 95% confidence interval [95% CI] 2.91-9.42] was the main GDM risk factor in both groups. Other GDM risk factors varied between groups. Perinatal outcomes in Chinese women with and without GDM were similar, except for neonatal hypoglycemia (aOR 2.01; 95% CI 1.14-3.56]. Caucasian women with GDM had more adverse perinatal outcomes than women without GDM. After adjusting for confounders, Chinese women with GDM had a lower risk of labor induction, large-for-gestational-age babies, neonatal hypoglycemia, respiratory distress, and low Apgar scores than Caucasian women with GDM.

CONCLUSIONS

Differences in prevalence, risk profile, and adverse outcomes in GDM were evident between ethnic Chinese and Caucasian women. A precision medicine approach to GDM may be warranted considering ethnicity and individual risk profiles rather than a one-size-fits-all approach.

Intergenerational Effects of Health Issues Among Women of Childbearing Age: a Review of the Recent Literature

PURPOSE OF REVIEW

This review summarizes the latest scientific evidence, primarily from systematic reviews/meta-analyses and large cohort studies, on the impact of health issues among women of childbearing age and their effect on their offspring during pregnancy and from birth to adulthood.

RECENT FINDINGS

Women of childbearing age with overweight/obesity, diabetes, and hypertension prior to pregnancy are at increased risk for adverse outcomes during pregnancy, such as excessive gestational weight gain, gestational diabetes mellitus, and hypertensive disorders of pregnancy. These adverse outcomes could complicate delivery and put their offspring at risk of developing overweight/obesity, diabetes, and hypertension (i.e., intergenerational transmission of health issues). Interventions should target women of childbearing age, especially those who wish to conceive, in order to possibly stop the transmission of women's health issues to the offspring and favor a healthy pregnancy from the start. This could be one of the best strategies to promote both maternal and child health.

Birth weight and risk of type 2 diabetes: A dose-response meta-analysis of cohort studies

The association between birth weight and type 2 diabetes mellitus has been debated for several decades. The objective of this systematic review and meta-analysis was to quantitatively clarify the association between birth weight and risk of type 2 diabetes mellitus based on cohort studies. We searched PubMed, Web of Science, and Embase databases for cohort study articles on the association between birth weight and risk of type 2 diabetes mellitus published up to 1 March 2018. Random effects of generalized least square regression models were used to estimate relative risk (RR). Restricted cubic splines were conducted to model the dose-response relationship. We included 21 studies (19 articles) involving 1 041 879 individuals and 35 699 cases of type 2 diabetes mellitus, with follow-up ranged from 6 to 47 years. We identified significant decreasing trend for the highest versus lowest category of birth weight for the association with type 2 diabetes mellitus risk: The risk was reduced by 35% (RR, 0.65; 95% confidence interval [CI], 0.53-0.81) and by 12% (RR 0.88; 95% CI, 0.85-0.91) per 500-g increment in birth weight. Our results showed a dose-response relationship between birth weight and diabetes risk, which was nonlinear (P_nonlinearity  < 0.001) and L-shaped. With increasing birth weight (<5000 g), the risk of type 2 diabetes mellitus decreased substantially. The association between birth weight and type 2 diabetes mellitus was curvilinear and L-shaped.

Real-World Experience of Adding Metformin in Pregnant Women with Type 1 Diabetes in a Chinese Population: A Retrospective Cohort

INTRODUCTION

Glycemic control in pregnant women with type 1 diabetes (T1D) is challenging with only insulin, and the incidence rate of adverse perinatal outcomes is high. Increasing data have indicated the safety and effect of metformin in pregnancy; however, no relevant data are available in pregnant women with T1D. We aimed to investigate glycemic control and perinatal outcomes in pregnant women with T1D in a Chinese population and explored the role of metformin in these patients.

METHODS

We obtained data of 38 pregnant women with T1D who received regular antenatal care and delivered at Peking Union Medical College Hospital (PUMCH) between 1 January 2006 and 31 May 2018. The perinatal outcomes of T1D patients who added metformin as adjunct treatment and those who remained on insulin-alone therapy were compared retrospectively.

RESULTS

Being overweight was common (35.1%) in pregnant women with T1D. On average, the insulin dose increased by 35.30 ± 22.60 unit/day during pregnancy. The cesarean delivery rate was high (65.8%), and fetal macrosomia was the main reason. The change of HbA1c in the metformin-insulin group was more prominent than in the insulin-only group (- 1.47 ± 1.17% vs. - 0.90 ± 1.13%, p = 0.05). There was no statistically significant difference in perinatal outcomes between the two groups.

CONCLUSIONS

The incidence of adverse perinatal outcomes in pregnant women with T1D was high. This study innovatively suggested that metformin could be safe and could contribute to improving glucose management in pregnant women with T1D.

The place of antenatal corticosteroids in late preterm and early term births

Infants born in the late preterm period and via non-labour caesarean section in the early term period are at increased risk of respiratory morbidity when compared to their term-born counterparts. The morbidity in these infants is less frequent and severe than in early preterm infants. Antenatal corticosteroids reduce respiratory morbidity in these populations; however, the magnitude of the reduction appears to be small and predominantly in the self-limiting condition of transient tachypnoea of the neonate. The smaller benefit, along with possible harmful effects of corticosteroids, raises a question about the role of antenatal corticosteroids in this population. Special obstetric populations such as twin pregnancies and pregnancies complicated by diabetes and growth restriction are at increased risk of prematurity and more vulnerable to its complications. Nevertheless, there is limited evidence regarding the benefits of corticosteroids in these populations and potential concern regarding adverse effects. We recommend an individualised approach when administering corticosteroids at later gestations. In these specific obstetric populations, we do not currently recommend administering corticosteroids in the late preterm/early term periods until more evidence is available.

Higher rates of large-for-gestational-age newborns mediated by excess maternal weight gain in pregnancies with Type 1 diabetes and use of continuous subcutaneous insulin infusion vs multiple dose insulin injection

AIMS

To compare glycaemic control, maternal and neonatal outcomes in pregnancies with Type 1 diabetes, managed either by continuous subcutaneous insulin infusion, multiple daily insulin injection or switch from multiple daily insulin injection (MDI) to continuous subcutaneous insulin infusion (CSII) in early pregnancy.

RESEARCH DESIGN AND METHODS

Data from 339 singleton pregnancies were retrospectively reviewed. HbA_1c values were measured preconception and in each trimester. In a secondary analysis, use of CSII pre-pregnancy was compared with initiation of CSII during pregnancy.

RESULTS

MDI was used in 140 pregnancies (41.3%) and CSII was used in 199 (58.7%), including 34 pregnancies (10.0%) during which the women switched to CSII. In pregnancies during which CSII was used duration of diabetes [median (interquartile range) 16.0 (8.0-23.0) years vs 11.0 (5.5-17.5) years; P<0.001] was longer, and the Institute of Medicine recommendations for appropriate weight gain were exceeded more often (64.8% vs. 50.8%; P=0.01). CSII use and pre-pregnancy BMI were independent predictors of excess weight gain. There was no difference in glucose control, but CSII was associated with higher birth weight [median (interquartile range) 3720 (3365-4100) g vs 3360 (3365-4100) g; P<0.001] and higher large-for-gestational-age (LGA) rate (44.7% vs. 33.6%; P=0.04) than MDI. HbA_1c concentration in the third trimester and excess weight gain were predictive of LGA infants [odds ratio 2.33 (95% CI 1.54-3.51); P<0.001 and 1.89 (95% CI 1.02-3.51); P=0.04]. In pregnancies where CSII therapy was initiated in the first trimester and in those with pre-pregnancy use, similar glucose control and outcome was achieved.

CONCLUSIONS

There was no advantage of CSII with respect to glycaemic control and neonatal outcomes. The rate of LGA neonates was higher in the CSII group, possibly mediated by excess maternal weight gain, which was more frequent than in women treated with MDI.

Development of an integrated, district-wide approach to pre-pregnancy management for women with pre-existing diabetes in a multi-ethnic population

BACKGROUND

Poor diabetes management prior to conception, results in increased rates of fetal malformations and other adverse pregnancy outcomes. We describe the development of an integrated, pre-pregnancy management strategy to improve pregnancy outcomes among women of reproductive age with diabetes in a multi-ethnic district.

METHODS

The strategy included (i) a narrative literature review of contraception and pre-pregnancy interventions for women with diabetes and development of a draft plan; (ii) a chart review of pregnancy outcomes (e.g. congenital malformations, neonatal hypoglycaemia and caesarean sections) among women with type 1 diabetes (T1D) (n = 53) and type 2 diabetes (T2D) (n = 46) between 2010 and 2015 (iii) interview surveys of women with T1D and T2D (n = 15), and local health care professionals (n = 13); (iv) two focus groups (n = 4) and one-to-one interviews with women with T1D and T2D from an Australian background (n = 5), women with T2D from cultural and linguistically diverse (CALD) (n = 7) and indigenous backgrounds (n = 1) and partners of CALD women (n = 3); and (v) two group meetings, one comprising predominantly primary care, and another comprising district-wide multidisciplinary inter-sectoral professionals, where components of the intervention strategy were finalised using a Delphi approach for development of the final plan.

RESULTS

Our literature review showed that a range of interventions, particularly multifaceted educational programs for women and healthcare professionals, significantly increased contraception uptake, and reduced adverse outcomes of pregnancy (e.g. malformations and stillbirth). Our chart-review showed that local rates of adverse pregnancy outcomes were similarly poor among women with both T1D and T2D (e.g. major congenital malformations [9.1% vs 8.9%] and macrosomia [34.7% vs 24.4%]). Challenges included lack of knowledge among women and healthcare professionals relating to diabetes management and limited access to specialist pre-pregnancy care. Group meetings led to a consensus to develop a district-wide approach including healthcare professional and patient education and a structured approach to identification and optimisation of self-management, including contraception, in women of reproductive age with diabetes.

CONCLUSIONS

Sufficient evidence exists for consensus on a district-wide strategy to improve pre-pregnancy management among women with pre-existing diabetes.

Diabetes Technology Use Among Pregnant and Nonpregnant Women with T1D in the T1D Exchange

BACKGROUND

Gestational tight glycemic control is critical for women with type 1 diabetes (T1D). Limited data exist on the adoption and retention of diabetes technologies among women in different parity strata.

METHODS

We compared T1D management between T1D Exchange clinic registry participants (mean age 28 ± 9 years, 84% white non-Hispanic, and median T1D duration 13 years) who were pregnant at enrollment or year 1 follow-up ("recently pregnant" between 2010 and 2013, n = 214), ever (but not recently) pregnant (n = 1540), and never pregnant (n = 2586). We examined self-reported maternal and fetal outcomes in 130 women who delivered a baby within the last year.

RESULTS

Recently pregnant women had the lowest hemoglobin A1c (6.5% pregnant vs. 7.8% ever pregnant vs. 8.0% never pregnant, P < 0.001). Recently pregnant women reported the highest use of continuous subcutaneous insulin infusion (74% vs. 60% vs. 58%, adjusted P < 0.001) and continuous glucose monitor (CGM) (36% vs.17% vs. 12%, adjusted P < 0.001) therapies compared with ever or never pregnant women, respectively, after adjusting for age, diabetes duration, and socioeconomic status. Among women 18-25 years old, CGM use was highest among recently pregnant women (adjusted P = 0.0022). Never pregnant women 26-45 years old had a higher use of CGM compared with younger counterparts (adjusted P < 0.001). Adverse maternal and fetal outcomes were common.

CONCLUSIONS

Despite high uptake levels of advanced diabetes technologies among pregnant women, rates of adverse maternal and fetal outcomes remain high. More studies are needed to determine how these technologies could be best used in pregnancy and postpartum to improve health outcomes among women with T1D.

Large-for-Gestational-Age Neonates in Type 1 Diabetes and Pregnancy: Contribution of Factors Beyond Hyperglycemia

Despite significant reductions in serious adverse perinatal outcomes for women with type 1 diabetes in pregnancy, the opposite effect has been observed for fetal overgrowth and associated complications, such as neonatal hypoglycemia, shoulder dystocia, and admission to the neonatal intensive care unit. In addition, infants born large for gestational age (LGA) have an increased lifetime risk of obesity, diabetes, and chronic disease. Although exposure to hyperglycemia plays an important role, women who seemingly achieve adequate glycemic control in pregnancy continue to experience a greater risk of excess fetal growth, leading to LGA neonates and macrosomia. We review potential contributors to excess fetal growth in pregnancies complicated by type 1 diabetes. In addition to hyperglycemia, we explore the role of glycemic variability, prepregnancy overweight and obesity, gestational weight gain, and maternal lipid levels. Greater understanding of the stimuli that drive excess fetal growth could lead to targeted management strategies in pregnant women with type 1 diabetes, potentially reducing the incidence of LGA neonates and the inherent risk of acute and long-term complications.

Population-Based Risk Factors for Shoulder Dystocia

OBJECTIVE

To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women.

DESIGN

Retrospective observational study.

SETTING

Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama.

PARTICIPANTS

We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013.

METHODS

Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site.

RESULTS

When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors.

CONCLUSION

With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Racial/ethnic disparities in magnesium sulfate neuroprotection: a subgroup analysis of a multicenter randomized controlled trial

OBJECTIVE

Despite known racial disparities in obstetrics, as well as differences in magnesium pharmacodynamics according to race, the effect of race/ethnicity in magnesium sulfate (MgSO₄) use during pregnancy has not been studied. Whether some mothers are at increased risk of side effects, or infants at decreased neuroprotective effects is unknown. We analyze the effect of race/ethnicity in maternal/infant outcomes after MgSO₄ neuroprotection.

STUDY DESIGN

Subgroup analysis of a multicenter clinical trial (BEAM trial) where pregnant women at risk of preterm birth were randomized to either MgSO₄ or placebo. For this study, nonanomalous singleton pregnancies were studied. The effect of race in maternal/neonatal outcomes after MgSO₄ was analyzed with Breslow-Day and multifactorial ANOVA. Logistic regression was used to calculate odds ratios (OR) of complications according to race.

RESULTS

922 MgSO₄ and 972 placebo cases were included (45.0% African-American, 36.2% Caucasian, 17.8% Hispanics, and 1.0% Asians). Interaction analysis showed a significant effect of race/ethnicity (p = .043). Hispanics presented the highest frequency (88.3%, p < .001), as well as the highest odds of MgSO₄ side effects [OR(95%CI) = 6.6 (1.3-33.8)].

CONCLUSION

Hispanics present increased risk of magnesium toxicity compared to other racial/ethnic groups. Whether specific racial/ethnic groups require closer surveillance for early signs of magnesium toxicity needs to be further explored.

Pregnancy Outcomes and Insulin Requirements in Women with Type 1 Diabetes Treated with Continuous Subcutaneous Insulin Infusion and Multiple Daily Injections: Cohort Study

BACKGROUND

We aimed to compare glycemic control, insulin requirements, and outcomes in women with type 1 diabetes in pregnancy treated with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI).

METHODS

A retrospective cohort study was conducted of singleton pregnancies (>20 weeks gestation) in women with type 1 diabetes (2010-2015) at a specialist multidisciplinary maternity network in Australia. Antenatal characteristics, diabetes history and treatment details, and maternal and neonatal outcomes were compared for women with type 1 diabetes using CSII and MDI. Bolus calculator settings were reviewed for CSII. Data were obtained from individual medical records, linkage to pathology, and the Birthing Outcomes System database.

RESULTS

There were no differences in maternal characteristics or diabetes history between women managed with CSII (n = 40) and MDI (n = 127). Women treated with CSII required less insulin and less increase in total daily insulin dose/kg than MDI (40% vs. 52%). Both groups achieved similar glycemic control and no differences in pregnancy outcome. In the CSII group, carbohydrate:insulin ratios were intensified across gestation (30% breakfast, 27% lunch, 22% dinner), and insulin sensitivity factors (ISFs) changed little (7% breakfast, 0% lunch, -10% dinner).

CONCLUSIONS

There was no difference in glycemic control or pregnancy outcomes in women using CSII or MDI managed in a multidisciplinary setting. Greater adjustments are needed to ISFs with CSII therapy. Overall, these data do not support recommending CSII in pregnancy with potentially higher patient and staff demands and costs and lack of improvement in HbA1c and pregnancy outcomes.