Glycaemic control is associated with pre-eclampsia but not with pregnancy-induced hypertension in women with type I diabetes mellitus

The sFLT-1/PlGF Ratio for the Prediction of Preeclampsia-Related Adverse Fetal and Maternal Outcomes in Women with Preexisting Diabetes

To evaluate the predictive value of the sFlt-1/PlGF ratio for the prediction of preeclampsia in women with preexisting diabetes mellitus. This is a monocentric retrospective observational study conducted between January 2018 and December 2020. All singleton pregnancies with preexisting diabetes mellitus, who had a dosage of the sFlt-1/PlGF ratio between 30 and 34 + 6 weeks of gestation were included. The principal outcome was preeclampsia. The secondary outcomes were preterm preeclampsia, gestational hypertension, placental abruption, intrauterine fetal death, IUGR, small for gestational age and a composite outcome named "hypertensive disorder of pregnancy" including gestational hypertension, preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count). Of 63 patients, 22% presented preeclampsia. The area under the curve of sFlt-1/PlGF ratio was 0.90 (95% CI: 0.79-0.96) for the prediction of preeclampsia. The receiver operator characteristic analysis suggested that the optimal sFlt-1/PlGF cutoff to predict preeclampsia was 29, with a sensitivity of 86% (95% CI: 60.1-96.0) and a specificity of 92% (95% CI: 80.8-96.8). A cut-off of 38 provided a sensitivity of 71% (95% CI: 45.4-88.3), a specificity of 92% (95% CI: 80.8-96.8). Further analysis using multivariable methods revealed nephropathy was significantly associated with PE (p = 0.014). The use of the sFlt-1/PlGF ratio during the third trimester of pregnancy seems to be of interest as a prognostic tool to improve multidisciplinary management of patients with preexisting diabetes mellitus.

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.

Mid-Trimester Fetal Anterior Abdominal Wall Subcutaneous Tissue Thickness: An Early Ultrasonographic Predictor of Gestational Diabetes Mellitus

Background This study aimed to determine whether mid-trimester fetal anterior abdominal wall subcutaneous tissue thickness (FASTT) is an early sonographic predictor of gestational diabetes mellitus (GDM), as well as to study its correlation with maternal glycemic values on GDM screening at 24-28 weeks. Methodology We conducted a prospective, case-control study. FASTT was assessed at anomaly scan in 896 uncomplicated singleton pregnancies. The 75-gram oral glucose tolerance test (OGTT) was done for all included patients at 24-28 weeks. Women diagnosed with GDM were taken as cases and appropriately matched in equal numbers as controls. Statistical analysis was done using SPSS version 20 (IBM Corp., Armonk, NY, USA). Independent-samples t-test, chi-square test, receiver operating characteristic curve, and Pearson's correlation coefficient (r) were performed wherever applicable. Results A total of 93 cases and 94 controls were included. Fetuses of women with GDM had significantly higher mean FASTT at 20 weeks (1.605 ± 0.328 mm vs. 1.222 ± 0.121 mm; p < 0.001). The FASTT cut-off obtained was 1.35 mm (sensitivity = 79.6%, specificity = 87.2%, positive predictive value = 86%, negative predictive value = 81.2%). There was a moderate positive correlation between fasting blood sugar (FBS) and two-hour OGTT values and FASTT (r = 0.332, p < 0.001 and r = 0.399, p < 0.001, respectively). FASTT >1.35 mm had an independent predictive value for GDM and was associated with a 19.608-fold increased risk of GDM. Conclusions FASTT values greater than 1.35 mm at 20 weeks are associated with a significantly increased risk of GDM. In addition, FASTT correlates with FBS and two-hour OGTT at 24-28 weeks and is a simple predictor of GDM at 18-20 weeks.

Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis

BACKGROUND

The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population.

METHODS AND FINDINGS

We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes.

CONCLUSIONS

In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.

What is the role of glycemic control in the development of preeclampsia among women with type 1 diabetes?

OBJECTIVE

To investigate the role of glycemic control in development of preeclampsia (PE) in women with type 1 diabetes mellitus (T1DM).

METHODS

An observational case-control study comparing 244 women with type 1 diabetes and 488 controls was conducted. Among women with T1DM HbA1c, average daily glucose values, fasting, preprandial, 1-hour and 2-hour postprandial glucose levels, and daily 3 meals postprandial glucose areas were evaluated. Uterine artery pulsatility indices (PI) at 16, 20, 24 weeks' gestation were obtained. Data analysis included rates of PE in both groups, and association between glycemic control, uterine artery PI and development of PE among women with T1DM.

RESULTS

PE developed in 13.1% of diabetic women and in 3.5% of women in the control group (odds ratio 4.2; 95% CI 2.2-8.1). In multivariate logistic regression analysis, HbA1c in the 1st trimester, mean daily glucose level in the 1st and 2nd trimester, daily 3 meal postprandial glucose area in the 1st and 2nd trimester, and the uterine arteries PI at 24 weeks' gestation were found to be associated with development of PE. The uterine arteries PI showed a significant positive correlation with the 3 meal postprandial glucose area at 16, 20, 24 weeks.

CONCLUSION

In women with T1DM, poor glycemic control early in pregnancy is associated with an increased risk of subsequent PE. An association between poor placentation, as indicated by the increased PI of uterine arteries, and a maternal metabolic factor, that is the 3 meal post-prandial glucose area, has been shown, supporting the increased rate of PE among women with T1DM.

Type 1 Diabetes: Management in Women From Preconception to Postpartum

CONTEXT

This review presents an up-to-date summary on management of type 1 diabetes mellitus (T1DM) among women of reproductive age and covers the following time periods: preconception, gestation, and postpartum.

EVIDENCE ACQUISITION

A systematic search and review of the literature for randomized controlled trials and other studies evaluating management of T1DM before pregnancy, during pregnancy, and postpartum was performed.

EVIDENCE SYNTHESIS

Preconception planning should begin early in the reproductive years for young women with T1DM. Preconception and during pregnancy, it is recommended to have near-normal glucose values to prevent adverse maternal and neonatal outcomes, including fetal demise, congenital anomaly, pre-eclampsia, macrosomia, neonatal respiratory distress, neonatal hyperbilirubinemia, and neonatal hypoglycemia.

CONCLUSION

Women with T1DM can have healthy, safe pregnancies with preconception planning, optimal glycemic control, and multidisciplinary care.

Improving pregnancy outcomes in women with diabetes mellitus: modern management

Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.

Pumps or Multiple Daily Injections in Pregnancy Involving Type 1 Diabetes: A Prespecified Analysis of the CONCEPTT Randomized Trial

OBJECTIVE

To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT).

RESEARCH DESIGN AND METHODS

This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA_1c. The primary outcome was change in HbA_1c from randomization to 34 weeks' gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes.

RESULTS

At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA_1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA_1c (-0.55 ± 0.59 vs. -0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA_1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02).

CONCLUSIONS

In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.

Morphological and ultrastructural changes in the placenta of the diabetic pregnant Egyptian women

Diabetes mellitus (DM) is a chronic metabolic disease in which the body fails to produce enough insulin or increased tissue resistance to insulin. The diabetes may have profound effects on placental development and function. This study was designed to detect the placental changes in pregnancy associated with DM comparing these changes with normal placenta. The study was carried out on sixty full-term placentae; divided into three equal groups; control group (group I): placentae of normal pregnancy, uncontrolled diabetes (group II): placentae from pregnant women whose blood glucose is poorly controlled during pregnancy. Controlled diabetes (group III): includes placentae from diabetic women whose blood glucose is controlled during pregnancy. The placentae from group II tend to be heavier and exhibited immaturity of villi, villous edema, fibrosis, excessive syncytial knots formation and infarctions. In addition to, fibrinoid necrosis, increased thickness of vasculosyncytial membrane, syncytial basement membrane, microvillous abnormalities and vascular endothelial changes were demonstrated. The syncytial multivesicular knots were present in placentae of group II. The nuclei within these syncytial knots display condensed chromatin, either dispersed throughout the nucleus or in the form of dense peripheral clumps with and numerous cytoplasmic vacuoles. The syncytial basement membrane showed focal areas of increase in its thickness and irregularity. Villous cytotrophoblasts showed increased number and activity in the form of numerous secretory granules, abundant dilated RER, larger distorted mitochondria. Villous vessels showed various degrees of abnormalities in the form of endothelial cell enlargement, folding, thickening and protrusion of their luminal surfaces into vascular lumen making it narrower in caliber. In placentae of group III, most of these abnormalities decreased. In most of placentae of group III, the VSM appeared nearly normal in thickness and showed nearly normal composition of one layer of syncytiotrophoblastic cells, one layer of smooth, regular capillary endothelium and the space between them. Mild microvillous abnormalities were noted in few placentae as they appeared short and blunted with mild decrease in their number per micron. The electron picture of syncytial knots appeared nearly normal containing aggregations of small, condensed hyperchromatic nuclei, minimal vacuoles could be seen in the cytoplasm of syncytial knots. Syncytial basement membrane appeared regular and nearly normal in its thickness and composition coming in direct contact with fetal blood capillaries but mild abnormalities were noted in the basement membrane in few placentae as increased its thickness and deposition of fibers or fibrinoid. Regarding cytotrophoblasts in the terminal villi of placentae with controlled diabetes, these cells appeared nearly normal. They were scattered beneath the syncytium and were active containing mitochondria, rough endoplasmic reticulum, free ribosomes and a large nucleus with fine dispersed chromatin. The vascular ultrastructural pattern in terminal villi of placentae of this group showed no significant abnormalities and was normally distributed in the villous tree. The luminal surface of the vascular endothelium appeared regular smooth in the majority of placentae of this group. The endothelial cells appeared connected to each other with tight junctions. It could be concluded that whether if long-term diabetes is controlled or not, placentae of diabetic mother showed a variety of significant histological structural changes seen more frequently than in the placentae of pregnant women without diabetes.

Diabetic Nephropathy and Pregnancy

Women with diabetic nephropathy have challenging pregnancies, with pregnancy outcomes far worse than expected for the stage of chronic kidney disease. The underlying mechanisms that cause the adverse events remain poorly understood, but it is a widely held belief that substantial endothelial injury in these women likely contributes. Maternal hypertension, preeclampsia, and cesarean section rates are high, and offspring are often preterm and of low birth weight, with additional neonatal complications associated with glycemic control. This review will present the current evidence for maternal and fetal outcomes of women with diabetic nephropathy and describe prepregnancy, antenatal, and peripartum optimization strategies.

Glycated haemoglobin A1c as a predictor of preeclampsia in type 1 diabetic pregnant women: A systematic review and meta-analysis

OBJECTIVE

To examine the relationship between the increase of glycated haemoglobin A1c (HbA1c) levels and the risk of preeclampsia in pregnant with type 1 diabetes mellitus; and to determine from which trimester the increase of HbA1c levels better predicts the risk of suffering preeclampsia in type 1 diabetic pregnant women.

METHODS

We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews and Web of Science databases, from inception to May 2017, for observational studies addressing the association of HbA1c levels with preeclampsia. Fixed effects models were used to compute pooled estimates of odds ratio (OR) and respective 95% confidence intervals (95% CI) for preeclampsia in type 1 diabetic pregnant women. Additionally, subgroup analyses were performed based on pregnancy trimester.

RESULTS

Five published studies were included in the systematic review and meta-analysis. There was an increase in the risk of preeclampsia with a 1% increase of HbA1c during pregnancy (OR = 1.38; 95% CI 1.26-1.52, I²=0.0%). When analyses were performed based on pregnancy trimester to estimate the risk of preeclampsia with a 1% increase of HbA1c, pooled OR estimates were 1.37 (95% CI 1.24-1.51, I²=0.0%) for the first trimester and 1.67 (95% CI 1.44-1.93, I²=0.0%) for the second/third trimester.

CONCLUSION

HbA1c is a reliable predictor of preeclampsia in type 1 diabetic pregnant women. Our findings highlight the importance of including HbA1c measurements in the first antenatal visit to control the risk of preeclampsia in pregnant women. Systematic review registration: PROSPERO: CRD42017058394.

Urine albumin is a superior predictor of preeclampsia compared to urine plasminogen in type I diabetes patients

Pregnant women with type I diabetes mellitus (T1DM) are at increased risk of developing preeclampsia (PE). Plasminogen is aberrantly filtrated from plasma into tubular fluid in PE patients and activated to plasmin. Plasmin activates the epithelial sodium channel in the collecting ducts potentially causing impaired sodium excretion, suppression of the renin-angiotensin-aldosterone system, and hypertension in PE. The objective of the study was to test whether urinary total plasmin(ogen)/creatinine ratio and plasma concentration of aldosterone were better predictors of PE in pregnant women with T1DM compared with urine albumin and haemoglobin A_1C. The design was a longitudinal observational study of 88 pregnant T1DM patients at 2 Danish centers. Spot urine- and blood samples were collected at gestational weeks 12, 20, 28, 32, and 36. U-plasmin(ogen)/creatinine ratio increased during pregnancy. In gestational week 36, the ratio was significantly increased in the T1DM patients developing PE (P < .05). P-aldosterone was significantly increased in gestational week 20 in the group developing PE (P < .05). U-albumin/creatinine ratio was significantly increased and predicted PE at all tested gestational ages. U-albumin/creatinine ratio had a stronger association with the development of PE compared to u-total plasmin(ogen)/creatinine ratio and p-aldosterone. The positive association between u-total plasmin(ogen) and development of PE late in pregnancy is compatible with involvement in PE pathophysiology. The significance of albumin in urine emphasizes the importance of preventing renal complications when planning pregnancy in patients with type I diabetes.

Maternal and fetal outcomes of pregnant women with type 1 diabetes, a national population study

Pregnancy in women with type 1 diabetes is associated with poor maternal and neonatal outcomes. However, the risk of these outcomes has never been evaluated in an Asian national population. In this work, we report the maternal and fetal outcomes of pregnant women with type 1 diabetes in Taiwan. A total of 2,350,339 pregnancy records created between 2001 and 2012 were obtained from the National Health Insurance database and analyzed. Here, 630 pregnancy records were identified in women having type 1 diabetes. Compared with pregnant women without type 1 diabetes, pregnant women with the disease showed increased risk of multiple adverse outcomes, including preeclampsia, eclampsia, cesarean delivery, adult respiratory distress syndrome, pulmonary edema, sepsis, chorioamnionitis, pregnancy-related hypertension, puerperal cerebrovascular disorders, acute renal failure, and shock. Fetuses of type 1 diabetic mothers were at increased risk of stillbirth, premature birth, large for gestational age, low birth weight, and low Apgar score. Of the studied endpoints, only preeclampsia showed an improvement in the late period (2011-2012) when compared with the early period (2001-2010). These findings reveal that pregnant women with type 1 diabetes are at significantly increased risk of developing many adverse maternal and fetal outcomes. Therefore, pregnancy outcomes in women with type 1 diabetes should be improved.

Determinants of gestational diabetes mellitus: a case-control study

BACKGROUND

Gestational diabetes mellitus (GDM) is glucose intolerance first recognized during pregnancy. The objective of this study was to identify the determinant factors of GDM.

METHODS

An unmatched case-control study was conducted. Descriptive statistics were used to describe the profile of study participants and binary logistic regression was used to identify the determinants of GDM.

RESULTS

GDM was associated with history of abortion (AOR 5.05 [95% CI: 2.65-9.63]), family history of diabetes mellitus (AOR 8.63 [95% CI: 5.19-14.35]), chronic hypertension (AOR 4.63 [95% CI: 1.27-16.86]), dietary diversification score (AOR 2.96 [95% CI: 2-4.46]), regular physical exercise (AOR 0.03 [95% CI: 0.01-0.04]), history of infertility (AOR 6.19 [95%CI: 1.86-20.16]), history of Caesarean section (AOR 3.24 [95% CI: 1.58-6.63]), previous history of GDM (AOR 8.21 [95% CI: 3.18-21.24]), previous history of intrauterine fetal death (AOR 3.96 [95% CI: 1.56-10.04]), literacy (AOR 0.6 [95% CI: 0.43-0.85]), body mass index (AOR 2.96 [95% CI: 2.08-4.2]), parity (AOR 1.78 [95% CI: 1.3-2.49]).

CONCLUSIONS

Regular physical exercise should be used as the main tool in preventing GDM.

Maternal overweight and obesity and risk of pre-eclampsia in women with type 1 diabetes or type 2 diabetes

AIMS/HYPOTHESIS

Women with type 1 or type 2 diabetes are at increased risk of pre-eclampsia. Overweight and obesity are associated with an increased risk of pre-eclampsia in women without diabetes. The aim of the study was to investigate the impact of maternal overweight and obesity on the risk of pre-eclampsia in women with type 1 diabetes or type 2 diabetes.

METHODS

In a population-based cohort study including singleton births in Sweden, we estimated the risk of pre-eclampsia among women with type 1 diabetes (n = 7062) and type 2 diabetes (n = 886), and investigated whether maternal overweight (BMI 25-29.9 kg/m(2)) and obesity (BMI ≥30.0 kg/m(2)) modified the risk. Logistic regression analyses were used to estimate crude and adjusted ORs with 95% CIs, using women without diabetes as the reference group (n = 1,509,525).

RESULTS

Compared with women without diabetes, the adjusted ORs for pre-eclampsia in women with type 1 and type 2 diabetes were 5.74 (95% CI 5.31, 6.20) and 2.11 (95% CI 1.65, 2.70), respectively. The corresponding risks of pre-eclampsia combined with preterm birth were even higher. Risks of pre-eclampsia increased with maternal overweight (BMI 25-29.9 kg/m(2)) and obesity (BMI ≥30.0 kg/m(2)), foremost in women without diabetes, to a lesser extent in women with type 1 diabetes but not in women with type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Maternal overweight and obesity increased risks of pre-eclampsia in women with type 1 diabetes but not in women with type 2 diabetes. Even so, considering associations between maternal BMI and overall maternal and offspring risk, all women (with and without diabetes) should aim for a normal weight before pregnancy.

AISF position paper on liver transplantation and pregnancy: Women in Hepatology Group, Italian Association for the Study of the Liver (AISF)

After the first successful pregnancy in a liver transplant recipient in 1978, much evidence has accumulated on the course, outcomes and management strategies of pregnancy following liver transplantation. Generally, liver transplantation restores sexual function and fertility as early as a few months after transplant. Considering that one third of all liver transplant recipients are women, that approximately one-third of them are of reproductive age (18-49 years), and that 15% of female liver transplant recipients are paediatric patients who have a >70% probability of reaching reproductive age, the issue of pregnancy after liver transplantation is rather relevant, and obstetricians, paediatricians, and transplant hepatologists ever more frequently encounter such patients. Pregnancy outcomes for both the mother and infant in liver transplant recipients are generally good, but there is an increased incidence of preterm delivery, hypertension/preeclampsia, foetal growth restriction, and gestational diabetes, which, by definition, render pregnancy in liver transplant recipients a high-risk one. In contrast, the risk of congenital anomalies and the live birth rate are comparable to those of the general population. Currently there are still no robust guidelines on the management of pregnancies after liver transplantation. The aim of this position paper is to review the available evidence on pregnancy in liver transplant recipients and to provide national Italian recommendations for clinicians caring for these patients.

Evaluation of biomarkers for the prediction of pre-eclampsia in women with type 1 diabetes mellitus: A systematic review

BACKGROUND

Pre-eclampsia is a leading cause of maternal and perinatal morbidity and mortality. Women with type 1 diabetes are considered a high-risk group for developing pre-eclampsia. Much research has focused on biomarkers as a means of screening for pre-eclampsia in the general maternal population; however, there is a lack of evidence for women with type 1 diabetes.

OBJECTIVES

To undertake a systematic review to identify potential biomarkers for the prediction of pre-eclampsia in women with type 1 diabetes.

SEARCH STRATEGY

We searched Medline, EMBASE, Maternity and Infant Care, Scopus, Web of Science and CINAHL SELECTION CRITERIA: Studies were included if they measured biomarkers in blood or urine of women who developed pre-eclampsia and had pre-gestational type 1 diabetes mellitus Data collection and analysis A narrative synthesis was adopted as a meta-analysis could not be performed, due to high study heterogeneity.

MAIN RESULTS

A total of 72 records were screened, with 21 eligible studies being included in the review. A wide range of biomarkers was investigated and study size varied from 34 to 1258 participants. No single biomarker appeared to be effective in predicting pre-eclampsia; however, glycaemic control was associated with an increased risk while a combination of angiogenic and anti-angiogenic factors seemed to be potentially useful.

CONCLUSIONS

Limited evidence suggests that combinations of biomarkers may be more effective in predicting pre-eclampsia than single biomarkers. Further research is needed to verify the predictive potential of biomarkers that have been measured in the general maternal population, as many studies exclude women with diabetes preceding pregnancy.

Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding

In women with preexisting diabetes and nephropathy or microalbuminuria, it is important to deliver careful preconception counselling to assess the risk for the mother and the foetus, for optimizing glycaemic status and to adjust medical treatment. If serum creatinine is normal in early pregnancy, kidney function is often preserved during pregnancy, but complications such as severe preeclampsia and preterm delivery are still common. Perinatal mortality is now comparable with that in women with diabetes and normal kidney function. Besides strict glycaemic control before and during pregnancy, early and intensive antihypertensive treatment is important to optimize pregnancy outcomes. Methyldopa, labetalol, nifedipine and diltiazem are considered safe, whereas angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers should be stopped before or at confirmation of pregnancy. Supplementation with folic acid in early pregnancy and low-dose aspirin from 10 to 12 weeks reduces the risk of adverse pregnancy outcomes. During breastfeeding, several ACE inhibitors are considered safe.

White's classification and pregnancy outcome in women with type 1 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

Our aim was to examine the association of White's classification with obstetric and perinatal risk factors and outcomes in type 1 diabetic patients.

METHODS

Obstetric records of a population-based cohort of 1,094 consecutive type 1 diabetic patients with a singleton childbirth during 1988-2011 were studied. The most recent childbirth of each woman was included.

RESULTS

The prepregnancy and the first trimester HbA1c increased from White's class B to F (p for trend <0.001). Systolic and diastolic blood pressure and pre-eclampsia frequencies increased stepwise from class B to F (p for trends <0.001). Vaginal deliveries decreased and Caesarean sections and deliveries before 37 weeks increased from class B to F (p for trends <0.001). Fetal macrosomia (p for trend=0.003) decreased and small-for-gestational age infants (p for trend=0.002) and neonatal intensive care unit admissions (p for trend=0.001) increased from class B to F. In logistic regression analysis, White's classes were associated with pre-eclampsia but, with the exception of class R (proliferative retinopathy) and F (nephropathy), not with other adverse outcomes when adjusted for first trimester HbA1c ≥7% (≥53 mmol/mol) and blood pressure ≥140/90 mmHg. First trimester HbA1c ≥7% was associated with pre-eclampsia, preterm delivery, fetal macrosomia and neonatal intensive care unit admission.

CONCLUSIONS/INTERPRETATION

White's classification is useful in estimating the risk of pre-eclampsia in early pregnancy independently of suboptimal glycaemic control and hypertension. However, its utility in predicting adverse perinatal outcomes seems limited when information on first trimester HbA1c, blood pressure and diabetic microvascular complications is available.

Pregnancy planning in type 1 diabetic women improves glycemic control and pregnancy outcomes

OBJECTIVE

Pregnancy in women with type 1 diabetes is associated with increased risks. The aim of this study was to evaluate the effect of pregnancy planning on outcomes of type 1 diabetic pregnancies.

METHODS

We retrospectively assessed pregnancy outcomes of type 1 diabetic women who were patients of Diabetes Clinic of North Karelia hospital between 2000 and 2012. We evaluated the medical records of 73 women experiencing 145 pregnancies and data of their infants.

RESULTS

Altogether 96 (66.2%) pregnancies were planned. HbA1c levels were significantly lower before and during the whole pregnancy when pregnancy was planned than if it was not planned (all p <0.001). Planned pregnancies resulted in significantly fewer congenital anomalies (p <0.001). Pregnancy planning reduced the age-adjusted risk of Cesarean sections (OR 0.25, p = 0.021). Pregnancy planning was associated with a reduced risk of adverse pregnancy outcomes (including miscarriages and congenital anomalies). This association was independent of age, HbA1c before pregnancy, smoking, hypertension, microvascular complications, and thyroid disease (OR 0.26; 95% CI 0.09, 0.76).

CONCLUSIONS

Pregnancy planning is beneficial for glycemic control and pregnancy outcomes of type 1 diabetic women. The benefit of pregnancy planning was independent of other risk factors for adverse pregnancy outcomes.

Health after pregnancy in the mother with diabetes

Progression of retinopathy and nephropathy in women with diabetes occurs, at least temporarily, during pregnancy and postpartum. However, normotensive pregnancy seems to have no detrimental effects regarding the long-term progression of any microvascular complication. Increased risk from pregnancy induced hypertension without proteinuria and with proteinuria (pre-eclampsia) relates mainly to the association with kidney disease in diabetes, and poor glycemic control. A history of pre-eclampsia or pregnancy induced hypertension is an important prognostic factor for micro- and macro-vascular complications later in life. Data regarding the long-term effects of hypertensive pregnancies on late complications of diabetes suggest that women with diabetes should be monitored regularly and nephroprotective treatment initiated early.

Impact of maternal diabetes mellitus on mortality and morbidity of very low birth weight infants: a multicenter Latin America study

OBJECTIVES

To compare mortality and morbidity in very low birth weight infants (VLBWI) born to women with and without diabetes mellitus (DM).

METHODS

This was a cohort study with retrospective data collection (2001-2010, n=11.991) from the NEOCOSUR network. Adjusted odds ratios and 95% confidence intervals were calculated for the outcome of neonatal mortality and morbidity as a function of maternal DM. Women with no DM served as the reference group.

RESULTS

The rate of maternal DM was 2.8% (95% CI: 2.5-3.1), but a significant (p=0.019) increase was observed between 2001-2005 (2.4%, 2.1-2.8) and 2006-2010 (3.2%, 2.8-3.6). Mothers with DM were more likely to have received a complete course of prenatal steroids than those without DM. Infants of diabetic mothers had a slightly higher gestational age and birth weight than infants of born to non-DM mothers. Distribution of mean birth weight Z-scores, small for gestational age status, and Apgar scores were similar. There were no significant differences between the two groups regarding respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, and patent ductus arteriosus. Delivery room mortality, total mortality, need for mechanical ventilation, and early-onset sepsis rates were significantly lower in the diabetic group, whereas necrotizing enterocolitis (NEC) was significantly higher in infants born to DM mothers. In the logistic regression analysis, NEC grades 2-3 was the only condition independently associated with DM (adjusted OR: 1.65 [95% CI: 1.2 -2.27]).

CONCLUSIONS

VLBWI born to DM mothers do not appear to be at an excess risk of mortality or early morbidity, except for NEC.

Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988-2011

AIMS/HYPOTHESIS

Our aim was to analyse possible changes in the glycaemic control, BP, markers of renal function, and obstetric and perinatal outcomes of parturients with diabetic nephropathy during 1988-2011.

METHODS

The most recent childbirth of 108 consecutive type 1 diabetes patients with diabetic nephropathy and a singleton pregnancy were studied. Two periods, 1988-1999 and 2000-2011, were compared.

RESULTS

The prepregnancy and the first trimester median HbA1c values persisted at high levels (8.2% [66 mmol/mol] vs 8.5% [69 mmol/mol], p = 0.16 and 8.3% [67 mmol/mol] vs 8.4% [68 mmol/mol], p = 0.67, respectively), but decreased by mid-pregnancy (6.7% [50 mmol/mol] vs 6.9% [52 mmol/mol], p = 0.11). Antihypertensive medication usage increased before pregnancy (34% vs 65%, p = 0.002) and in the second and third trimesters of pregnancy (25% vs 47%, p = 0.02, and 36% vs 60%, p = 0.01, respectively). BP exceeded 130/80 mmHg in 62% and 61% (p = 0.87) of patients in the first trimester, and in 95% and 93% (p = 0.69) in the third trimester, respectively. No changes were observed in the markers of renal function. Pre-eclampsia (52% vs 42%, p = 0.29) and preterm birth rates before 32 and 37 gestational weeks (14% vs 21%, p = 0.33, and 71% vs 77%, p = 0.49, respectively) remained high. The elective and emergency Caesarean section rates were 71% and 45% (p = 0.01) and 29% and 48% (p = 0.05), respectively. Neonatal intensive care unit admissions increased from 26% to 49% (p = 0.02).

CONCLUSIONS/INTERPRETATION

Early pregnancy glycaemic control and hypertension management were suboptimal in both time periods. Pre-eclampsia and preterm delivery rates remained high in patients with diabetic nephropathy.

Risk factors of hypertensive pregnancies in women with diabetes and the influence on their future life

Diabetic women carry a 2-4 times increased risk of a hypertensive pregnancy compared to non-diabetic people. This risk is related to presence of diabetic nephropathy, but also poor glycaemic control. Efforts to improve glycaemic control have decreased perinatal morbidity and mortality related to diabetic nephropathy. Despite good glycaemic control, overt nephropathy is associated with a variety of pregnancy complications, such as fetal growth restriction and pre-eclampsia. General population studies show that women with a history of pre-eclampsia are more prone to develop cardiovascular disease later in life than women with a history of normotensive pregnancy. Furthermore, recent data regarding the long-term effects of hypertensive pregnancies on late diabetic complications indicate that these women should be followed and treatment should be started early. In this review we summarize data on risk factors and long-term effects of hypertensive pregnancies on late diabetic complications that may be of clinical relevance in the prevention of these complications.

The association of circulating angiogenic factors and HbA1c with the risk of preeclampsia in women with preexisting diabetes

Objective:

To assess whether glycemic control, soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) were associated with the development of preeclampsia (PE) or gestational hypertension (GHTN) in women with preexisting diabetes.

Methods:

Maternal circulating angiogenic factors (sFlt1 and PlGF) measured on automated platform were studied at four time points during pregnancy in women with diabetes (N = 159) and reported as multiples of the median (MOM) of sFlt1/PlGF ratio (median, 25th–75th percentile) noted in non-diabetic non-hypertensive control pregnant population (N = 139). Diagnosis of PE or GHTN was determined by review of de-identified clinical data.

Results:

PE developed in 12% (N = 19) and GHTN developed in 23% (N = 37) of the women with diabetes. Among diabetic women without PE or GHTN, median sFlt1/PlGF levels at 35–40 weeks was threefold higher than in non-diabetic controls [MOM 3.21(1.19–7.24), p = 0.0001]. Diabetic women who subsequently developed PE had even greater alterations in sFlt1/PlGF ratio during the third trimester [MOM for PE at 27–34 weeks 15.18 (2.37–26.86), at 35–40 weeks 8.61(1.20–18.27), p ≤ 0.01 for both windows compared to non-diabetic controls]. Women with diabetes who subsequently developed GHTN also had significant alterations in angiogenic factors during third trimester; however, these findings were less striking. Among women with diabetes, glycosylated hemoglobin (HbA1c) during the first trimester was higher in subjects who subsequently developed PE (7.7 vs 6.7%, p = 0.0001 for diabetic PE vs diabetic non-PE).

Conclusions:

Women with diabetes had a markedly altered anti-angiogenic state late in pregnancy that was further exacerbated in subjects who developed PE. Altered angiogenic factors may be one mechanism for the increased risk of PE in this population. Increased HbA1c in the first trimester of pregnancies in women with diabetes was strongly associated with subsequent PE.

An update on diabetic women obstetrical outcomes linked to preconception and pregnancy glycemic profile: a systematic literature review

Women with type 2 diabetes were less likely to have diabetes related complications than women with type 1. Women with type 1 diabetes had a high prepregnancy care and showed a worse glycemic control than women with type 2 both in the preconception period and during pregnancy. Obstetrical outcomes showed that preeclampsia and stillbirth rate is almost doubled in type 1 patients while perinatal deaths and SGA importantly increased in type 2 diabetes. In modern obstetrical care it is mandatory to maintain glucose levels as close to normal as possible particularly in diabetic population. HbA1C no higher than 6% before pregnancy and during the first trimester seems to decrease the risk of adverse obstetrical outcomes. Both the preconceptional counseling and glycemic profile optimization represent a fundamental step to improve pregnancy outcomes in women with preexisting diabetes. A systematic approach to family planning and the availability of preconception care for all diabetic women who desire pregnancy could be an essential step for diabetic management program.

Pre-eclampsia and pregnancy-induced hypertension are associated with severe diabetic retinopathy in type 1 diabetes later in life

To investigate whether pre-eclampsia (PE) or pregnancy-induced hypertension (PIH) predicts the development of severe diabetic retinopathy (SDR) in type 1 diabetes. Altogether, 203 women with type 1 diabetes who were followed during pregnancy were re-examined within the Finnish Diabetic Nephropathy Study. After excluding patients with pre-pregnancy hypertension and those who had had laser treatment or whose retinopathy was graded as proliferative at the index pregnancy, 158 were prospectively studied. As a surrogate marker for SDR, retinal laser photocoagulation was used. The time from pregnancy to SDR (N = 21) or follow-up was 16 years (interquartile range, 11-19). HbA1c was repeatedly measured both during pregnancy and follow-up. Women with prior PE (26 % vs. 6 %, P = 0.003) or PIH (24 % vs. 6 %, P = 0.008) had more often incident SDR during follow-up compared to those with normotensive pregnancy. The hazard ratios (HR) remained associated with the progression to SDR after adjustment for duration of diabetes and diabetic nephropathy in a Cox regression analysis [PE: 3.5 (95 % CI 1.1-10.9); P = 0.03 and for PIH: 3.2 (1.1-9.8); P = 0.04]. The association between PIH and incident SDR did not change after inclusion of mean HbA1c, measured during pregnancy (all 3 trimesters) and serial HbA1c measurements during follow-up, 3.5 (1.1-11.8; P = 0.03). However, in a similar model, the HR for PE was no more significant 2.0 (0.6-6.8; P = NS). The results suggest that women with type 1 diabetes and a hypertensive pregnancy have an increased risk of severe diabetic retinopathy later in life.

Blood pressure levels but not hypertensive complications have increased in Type 1 diabetes pregnancies during 1989-2010

AIMS

The pre-pregnancy BMI and the third trimester HbA(1c) levels increased in Finnish parturients with Type 1 diabetes during 1989-2008. The aim of the present study was to investigate whether these trends have been accompanied by increases in blood pressure or hypertensive complications. Hypertension trends were analysed using the definitions of hypertension of both the American College of Obstetricians and Gynecologists and the American Diabetes Association. The associations of hypertension, as defined by the latter criteria, with perinatal complications were also studied.

METHODS

The records of a cohort of 1007 consecutive patients with Type 1 diabetes with a singleton live childbirth during 1989-2010 at the Helsinki University Central Hospital were studied.

RESULTS

The frequencies of hypertensive pregnancy complications did not change, but the mean diastolic blood pressure increased in normotensive parturients in all trimesters. The proportion of patients with systolic blood pressure > 130 mmHg or diastolic blood pressure > 80 mmHg in the first, second and third trimesters of pregnancy increased from 25 to 33%, from 26 to 35% and from 57 to 71%, respectively. Systolic blood pressure of 131-139 mmHg or diastolic blood pressure of 81-89 mmHg in the third trimester was associated with umbilical artery pH < 7.15.

CONCLUSIONS

Blood pressure of patients with Type 1 diabetes during pregnancy is increasing. A growing proportion of women with Type 1 diabetes exceed the American Diabetes Association's definition of hypertension during pregnancy.

Reproduction and autoimmune disease: important translational implications from embryo–maternal interaction

Pregnancy and autoimmune disorders (ADs) coexist in a delicate balance. Whereas women are disproportionately affected by ADs – frequently occurring during reproductive years – the disease often improves during pregnancy, unless severe. However, when ADs are at an advanced stage, both mother and fetus can be severely affected. Maternal AD amelioration reduces fetal morbidity/mortality. AD improvement occurs without compromising immune tolerance for the fetus; however, it is short-lived since postpartum, flare-up frequently occurs. Consequences of pregnancy-related maternal disease can have life-long impact. Pregnancy is not an immune-suppressed state, but rather a controlled inflammatory environment with distinct local and systemic coordination. Pregnancy requires a delicate immune balance; the embryo/allograft does not cause graft-versus-host disease while the mother/host immunity is modulated without suppression. We herein critically examine the synergetic reciprocal relationship between pregnancy and ADs. We review key ADs and their current prognosis and management. Finally, we describe PreImplantation Factor, a peptide secreted by viable embryos that, beyond its essential autotrophic and proimplantation properties, regulates systemic immune response and also proved effective in nonpregnant autoimmune and transplantation models. Hence, PreImplantation Factor may have a key role in improving ADs in pregnancy, and provide a novel drug for treatment of immune disorders in general.

New technologies for the management of pregestational diabetes mellitus

PURPOSE OF THE REVIEW

The purpose of this review is to understand new modalities available to treat and manage type 1 and type 2 diabetes during pregnancy.

RECENT FINDINGS

The use of new insulin analogs and oral agents, as well as new technologies to deliver insulin and monitor glucose during pregnancy remains controversial. This review will outline the advantages and disadvantages, as well as the safety profiles of these new medications and therapeutic options.

SUMMARY

There are many effective treatments for diabetes during pregnancy. New insulin analogs seem to be safe to use in pregnancy and offer the potential for better glycemic control compared with older agents. Oral hypoglycemic medications also seem to be safe and may be an option for a select group of pregnant patients with type 2 diabetes. Insulin pumps and continuous glucose monitoring systems may be beneficial in certain patients, but adequate data are not yet available in terms of outcomes and cost-effectiveness to support widespread use.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After participating in this CME activity, physicians should be better able to revise glycemic goals for pregnant patients with pregestational diabetes to be in line with our current understanding of glycemic profiles in normal pregnant women. Use new insulin analogs to treat pregnant women with abnormalities in glucose homeostasis and choose which patients will benefit from advanced technologies for diabetes management, such as insulin pumps and continuous glucose monitoring systems.

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989-2008

AIMS/HYPOTHESIS

Our objective was to examine the trends in prepregnancy BMI and glycaemic control among Finnish type 1 diabetic patients and their relation to delivery mode and perinatal outcome.

METHODS

We analysed the obstetric records of 881 type 1 diabetic women with a singleton childbirth during 1989-2008. Maternal prepregnancy weight and height were obtained from the maternity cards, where they are recorded as reported by the mother.

RESULTS

Maternal BMI increased significantly during 1989-2008 (p < 0.001). The mean HbA(1c) in the first trimester remained unchanged, but the midpregnancy and the last HbA(1c) before delivery increased (p = 0.009 and 0.005, respectively). Elective Caesarean sections (CS) decreased (p for trend <0.001), while emergency CS increased (p for trend <0.001). The mean umbilical artery (UA) pH decreased in vaginal deliveries (p for trend <0.001). The frequency of UA pH <7.15 and <7.05 increased (p for trend <0.001 and 0.008, respectively). The macrosomia rate remained at 32-40%. Neonatal intensive care unit (NICU) admissions increased (p for trend 0.03) and neonatal hypoglycaemia frequency decreased (p for trend 0.001). In multiple logistic regression analysis, maternal BMI was associated with macrosomia and NICU admission. The last HbA(1c) value before delivery was associated with delivery before 37 weeks' gestation, UA pH <7.15, 1 min Apgar score <7, macrosomia, NICU admission and neonatal hypoglycaemia.

CONCLUSIONS/INTERPRETATION

Self-reported pregestational BMI has increased and glycaemic control during the second half of pregnancy has deteriorated. Poor glycaemic control seems to be associated with the observed increases in adverse obstetric and perinatal outcomes.

Obstetric nephrology: pregnancy in women with diabetic nephropathy--the role of antihypertensive treatment

This review highlights factors of importance for the clinical care of pregnant women with pregestational diabetes and microalbuminuria or diabetic nephropathy with particular focus on the role of intensive antihypertensive treatment during pregnancy. Most information in the literature comes from women with type 1 diabetes and diabetic nephropathy, but this is probably also valid for women with type 2 diabetes. Careful counseling of women with diabetic nephropathy before pregnancy with estimation of the risk for the mother and fetus is important. Pregnancy does not result in worsening of kidney function in women with diabetic nephropathy and normal serum creatinine, but pregnancy complications such as pre-eclampsia and preterm delivery are common. Intensive metabolic control before and during pregnancy, low-dose aspirin from 12 gestational weeks onward, and intensive antihypertensive treatment are important. Methyldopa, labetalol, and nifedipine are regarded safe in pregnancy, whereas angiotensin converting enzyme inhibitors, AngII antagonists, or statins should be paused before pregnancy. Case series and pathophysiological studies support the use of a stringent goal for BP and albumin excretion in pregnant women with diabetic nephropathy. Screening for diabetic retinopathy before and during pregnancy is mandatory and laser treatment should be performed if indicated. Pregnancy outcome in women with diabetic nephropathy has improved considerably with a take-home-baby rate of approximately 95%. Further research on the benefits and risks of intensive antihypertensive treatment in this population is needed.

HbA1c in pregnancy

During pregnancy, the glucose levels vary according to the hormonal changes and the metabolic needs necessary to maintain fetal nutrition but strict glycemic control is essential to minimize the maternal and fetal morbidity and mortality of pregnancies complicated by diabetes. Although considered the "gold standard" for diagnosis, measurement of glucose in the blood is subject to several limitations, many of which are not widely appreciated. Measurement of A1c for diagnosis is appealing as with one number, a total, integrated view of glycemia over time is derived though it has some inherent limitations. Thus, supplementation with HbA1c, as is common outside pregnancy, seems appropriate. Before pregnancy, the target for metabolic control in women with diabetes is HbA1c values near the normal range. However, the upper normal range of HbA1c during normal pregnancy is only sparsely investigated with different methods though recently a number of papers have been published regarding the determination of reference ranges for HbA1c in pregnancy. These changes may have clinical implications for the assessment and management of glycemic control in diabetic pregnancy and calls for establishment of separate reference limits of HbA1c levels in different trimesters as compared to general population.

[Diabetes and pregnancy]

Metabolic characteristics of physiological and diabetic pregnancies are discussed. The basic factor of these changes is the increasing insulin resistance throughout pregnancy, which in case of diabetes may result in hyperglycemia with undesirable clinical consequences and complications for both the mother and the fetus. Prevention of these complications by maintaining physiological metabolic state of diabetic pregnant women is possible, which is similar to that of healthy women. The aim of treatment of pregnant diabetics is to achieve normoglycemic state during the whole gestation that is possible by early diagnosis in case of gestational diabetes and by adequate preconception care in case of pregestational diabetes. To obtain desirable glycemic conditions insulin treatment is necessary in most of the cases together with adequate, quantitative nutrition therapy, while oral antidiabetic drugs during pregnancy and lactation are to be avoided. For adequate care of the cases with diabetes and pregnancy interdisciplinary diabetes centers with well-trained experts are required.

Optimal glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes in the diabetes and pre-eclampsia intervention trial

OBJECTIVE

To assess the relationship between glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Pregnancy outcome (pre-eclampsia or gestational hypertension) was assessed prospectively in 749 women from the randomized controlled Diabetes and Pre-eclampsia Intervention Trial (DAPIT). HbA(1c) (A1C) values were available up to 6 months before pregnancy (n = 542), at the first antenatal visit (median 9 weeks) (n = 721), at 26 weeks' gestation (n = 592), and at 34 weeks' gestation (n = 519) and were categorized as optimal (<6.1%: referent), good (6.1-6.9%), moderate (7.0-7.9%), and poor (≥8.0%) glycemic control, respectively.

RESULTS

Pre-eclampsia and gestational hypertension developed in 17 and 11% of pregnancies, respectively. Women who developed pre-eclampsia had significantly higher A1C values before and during pregnancy compared with women who did not develop pre-eclampsia (P < 0.05, respectively). In early pregnancy, A1C ≥ 8.0% was associated with a significantly increased risk of pre-eclampsia (odds ratio 3.68 [95% CI 1.17-11.6]) compared with optimal control. At 26 weeks' gestation, A1C values ≥ 6.1% (good: 2.09 [1.03-4.21]; moderate: 3.20 [1.47-7.00]; and poor: 3.81 [1.30-11.1]) and at 34 weeks' gestation A1C values ≥ 7.0% (moderate: 3.27 [1.31-8.20] and poor: 8.01 [2.04-31.5]) significantly increased the risk of pre-eclampsia compared with optimal control. The adjusted odds ratios for pre-eclampsia for each 1% decrement in A1C before pregnancy, at the first antenatal visit, at 26 weeks' gestation, and at 34 weeks' gestation were 0.88 (0.75-1.03), 0.75 (0.64-0.88), 0.57 (0.42-0.78), and 0.47 (0.31-0.70), respectively. Glycemic control was not significantly associated with gestational hypertension.

CONCLUSIONS

Women who developed pre-eclampsia had significantly higher A1C values before and during pregnancy. These data suggest that optimal glycemic control both early and throughout pregnancy may reduce the risk of pre-eclampsia in women with type 1 diabetes.

A high concentration of prorenin in early pregnancy is associated with development of pre-eclampsia in women with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this study was to investigate whether components of the renin-angiotensin system and semicarbazide-sensitive amine oxidase (SSAO) are associated with the development of pre-eclampsia in women with type 1 diabetes.

METHODS

This was an observational study of 107 consecutive pregnant women with type 1 diabetes (median duration 16 years [range 1-36 years], HbA(1c) 6.6% [range 4.9-10.5%]) in early pregnancy. At 8, 14, 21, 27 and 33 weeks and once within 5 days postpartum, blood was sampled for measurements of prorenin, renin, angiotensinogen, ACE and SSAO. HbA(1c), blood pressure and urinary albumin excretion were recorded. Pre-eclampsia was defined as blood pressure >140/90 mmHg and proteinuria ≥300 mg/24 h after 20 weeks.

RESULTS

Pre-eclampsia developed in nine women (8%) with longer diabetes duration (median 20 [range 10-32] vs 16 [range 1-36] years, p = 0.04), higher SSAO concentrations (592 [range 372-914] vs 522 [range 264-872] mU/l, p = 0.04) and a tendency towards higher prorenin levels (136 [range 50-296] vs 101 [range 21-316] ng angiotensin I ml(-1) h(-1), p = 0.06) at 8 weeks compared with women without pre-eclampsia. Levels of renin, angiotensinogen and ACE did not differ in the two groups. Throughout pregnancy, prorenin and SSAO levels were 30% (p = 0.004) and 16% (p = 0.04) higher, respectively, in women developing pre-eclampsia. Using multivariate logistic regression analysis, prorenin concentration at 8 weeks was associated with pre-eclampsia (OR 4.4 [95% CI 1.5-13.0], p = 0.007), i.e. an increase of prorenin of 100 ng angiotensin I ml(-1) h(-1) implies a 4.4 times higher risk of subsequent pre-eclampsia.

CONCLUSIONS/INTERPRETATION

In type 1 diabetic women with pre-eclampsia, a higher concentration of prorenin in early pregnancy and higher levels of prorenin and SSAO throughout pregnancy were seen.

Diabetes and the kidney in pregnancy

The prevalence of diabetes in pregnant women is increasing, with 4% of deliveries in the United States occurring in women with pregestational or gestational diabetes. The proteinuria of late pregnancy is exaggerated in women with diabetes. However, diabetic women with preserved renal function before pregnancy appear to have little risk of deterioration of kidney function during pregnancy. Women with impaired renal function before pregnancy may be at risk for permanent decline of renal function during pregnancy, although it is unclear whether this represents the effect of pregnancy or the natural history of their diabetic renal disease. Preeclampsia, which is more common in women with diabetes, may be difficult to diagnose in this group of women. From the currently available literature, there appears to be no negative effect of pregnancy on the long-term progression of diabetic renal disease if renal function is normal and marked proteinuria is absent, but in light of recent findings in which preeclampsia appears to be associated with an increased risk of end-stage renal disease, large cohort studies will be necessary before this question can be definitively answered.

Hypertension complicating diabetic pregnancies: pathophysiology, management, and controversies

Hypertensive disorders of pregnancy (HDP), including pre-existing hypertension, gestational hypertension, and preeclampsia, further complicate already high-risk pregnancies in women with diabetes mellitus (DM). Women with both pre-existing and gestational diabetes are at increased risk for HDP, leading to higher maternal and fetal morbidity. Further, particularly in diabetic women and women with a history of gestational diabetes, HDP significantly increases the risk for future cardiovascular events. For clinicians, women with hypertension and diabetes during pregnancy pose a management challenge. Specifically, preconception management should stress strict control of glycemia, blood pressure, and prevention of diabetic complications, specifically nephropathy, which specifically increases the risk for preeclampsia. During gestation, clinicians must be aware of potential maternal and fetal complications associated with various anti-hypertensive therapies, including known fetotoxicity of ACE inhibitors and ARBs when given in the 2nd or 3rd trimester, and the risks and benefits of expectant management versus delivery in cases of severe gestational hypertension or preeclampsia. Indeed, diabetic women must be followed closely prior to conception and throughout gestation to minimize the risk of HDP and its associated complications.

Hypertension in diabetic pregnancy: impact and long-term outlook

Hypertensive disorders in pregnancy can be chronic, pregestational or just diagnosed before the 20th week, or newly diagnosed in the second half of pregnancy. Any type of hypertension is more frequent in diabetic pregnancies with a different distribution among different types of diabetes. Most of the evidence is for pre-eclampsia associated with a marked increase in primary caesarean section, preterm birth and more need for neonatal intensive care. Different risk factors and pregnancy outcomes would support the hypothesis that pre-eclampsia and gestational hypertension might be largely separate entities, but this position is not unanimously accepted. Chronic hypertension increases with age and duration of diabetes, predicting increased rates of prematurity and neonatal morbidity, especially when associated with superimposed pre-eclampsia. Long-term consequences are observed in women whose pregnancy was complicated by hypertension such as chronic hypertension and cardiovascular diseases.

Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes

AIMS/HYPOTHESIS

We studied the progression of diabetic retinopathy during pregnancy in women with type 2 diabetes.

METHODS

Fundus photography was performed at median 10 (range 6-21) and 28 (27-37) gestational weeks in 80 of 110 (73%) consecutively referred pregnant women with type 2 diabetes. Diabetic retinopathy was classified in five stages. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of macular oedema on at least one eye between the two examinations. Macular oedema was defined as retinal thickening and/or hard exudates within a diameter of 1,500 microm in the macula area.

RESULTS

Diabetic retinopathy, mainly mild, was present in 11 (14%) women in early pregnancy. Median duration of diabetes was 3 years (range 0-16 years). At baseline, HbA(1c) was 6.4% (1.0) (mean [SD]), systolic BP 121 (13) and diastolic BP 72 (9) mmHg. Prior to pregnancy, 22 (28%) women had been on insulin treatment. During pregnancy 74 women (93%) were treated with insulin and 11 (14%) with antihypertensive medication. Progression of diabetic retinopathy was observed in 11 (14%) women. Progression was mainly mild, but one woman with poor glycaemic control and uncontrolled hypertension progressed from mild retinopathy to sight-threatening retinopathy with proliferations, clinically significant macular oedema and impaired vision in both eyes. Progression of diabetic retinopathy was associated with a longer duration of diabetes (p = 0.03) and insulin treatment before pregnancy (p = 0.004).

CONCLUSIONS/INTERPRETATION

Despite a low risk of progression of retinopathy in pregnant women with type 2 diabetes, sight-threatening deterioration did occur.