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Clement NS, Abul A, Farrelly R, Murphy HR, Forbes K, Simpson NAB, Scott EM. Pregnancy outcomes in type 2 diabetes: a systematic review and meta-analysis. Am J Obstet Gynecol 2025; 232:354-366. [PMID: 39662865 DOI: 10.1016/j.ajog.2024.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 11/13/2024] [Accepted: 11/28/2024] [Indexed: 12/13/2024]
Abstract
OBJECTIVE Type 2 diabetes (T2D) now accounts for the majority of pre-existing diabetes affecting pregnancy in the UK. Our aim was to determine its impact on pregnancy outcomes compared to type 1 diabetes (T1D), gestational diabetes (GDM), and nondiabetes pregnancies. DATA SOURCES PubMed was searched 1 January 2009 to 2024. STUDY ELIGIBILITY CRITERIA Cohort observational studies reporting original data on at least one of the primary outcomes in ten or more T2D pregnancies were eligible for inclusion. Comparative diabetes and nondiabetes pregnancies were also collected. METHODS Primary outcomes included congenital anomalies, stillbirths, neonatal and perinatal mortality, birthweight, rates of large for gestational age (LGA), small for gestational age (SGA), and macrosomia. PROSPERO ID CRD42023411057. RESULTS Forty seven studies were analyzed. The number of pregnancies in each analysis varied depending on the available data from the outcome being analyzed but ranged from 723 to 4,469,053 pregnancies. When compared with T1D pregnancies, T2D were more likely to have SGA babies as well as greater neonatal and perinatal mortality (OR 2.29, 95% CI 1.12-4.67; OR 1.53 95% CI 1.20-1.94, and OR 1.31 95% CI 1.07-1.61, respectively). When compared with GDM, T2D were more likely to have babies with congenital anomalies (OR 1.91, 95% CI 1.04-3.50), LGA (OR 3.49, 95% CI 2.49-4.89), neonatal mortality (OR 3.96, 95% CI 3.38-4.64), and stillbirth (OR 16.55, 95% CI 5.69-48.11). In comparison to nondiabetic pregnancy, T2D were more likely to have babies with congenital anomalies (OR 1.76, 95% CI 1.11-2.79), LGA (OR 2.79, 95% CI 1.93-4.04), perinatal mortality (OR 4.18, 95% CI 2.91-6.01), and stillbirth (OR 7.27, 95% CI 3.01-17.53). CONCLUSION T2D pregnancies are associated with a greater perinatal mortality than other forms of diabetes in pregnancy. Given its increasing prevenance, greater awareness of the adverse pregnancy outcomes associated with T2D is needed, by both healthcare providers and policy makers, to improve care.
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Affiliation(s)
- Naomi S Clement
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Ahmad Abul
- Division of Surgical and Interventional Sciences, University College London, London, UK
| | - Rachel Farrelly
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Karen Forbes
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Nigel A B Simpson
- Department of Women's and Children's Health, University of Leeds, Leeds, UK
| | - Eleanor M Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Fishel Bartal M, Nazeer SA, Ashby Cornthwaite J, Bitar G, Blackwell SC, Pedroza C, Chauhan SP, Saad A, Saade G, Sibai BM. Relationship between Intrapartum Continuous Glucose Monitoring Values and Neonatal Hypoglycemia in Individuals with Diabetes. Am J Perinatol 2024. [PMID: 39622499 DOI: 10.1055/a-2494-2157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2024]
Abstract
OBJECTIVE We aimed to evaluate the relationship between intrapartum continuous glucose monitoring (CGM) and neonatal hypoglycemia (NH) in individuals with diabetes. STUDY DESIGN a multicenter prospective study (November 2021-December 2022) of laboring individuals with pregestational or gestational diabetes at ≥34 weeks. Cohorts had a blinded CGM placed from admission through delivery and were monitored with fingerstick (FS) according to usual care. The primary outcome was NH. Secondary neonatal outcomes included neonatal intensive care unit (NICU) length of stay, need for intravenous (IV) glucose therapy, hyperbilirubinemia, respiratory distress, or respiratory distress syndrome. Time in the target range (TIR; range 70-110 mg/dL) and time above the target range (TAR; >110 mg/dL) were expressed as a percentage of all CGM readings, and mean glucose was obtained. Youden index was used to choose the cut point for TAR and prediction of NH. RESULTS Of 9,479 deliveries during the study period, 202 (2.1%) met the inclusion criteria, and 112 (56%) participants were enrolled (n = 7 did not have available CGM data). Of the study participants, 45 (40%) had pregestational diabetes, and 67 (60%) had gestational diabetes. The mean glucose in labor using a CGM was 102.6 mg/dL (interquartile range [IQR]:89.9, 113.5 mg/dL), and the average percentage of TIR was 62.1% (IQR, 36.9, 85.6). CGM and FS were poor predictors of NH, with no differences in area under the curve (AUC) of mean glucose as a predictor (0.64, 95% CI: 0.48-0.23 vs. 0.53, 95% CI: 0.4-0.6, respectively). The best cut-off for the prediction of NH was a TAR of 61%, with 23% (n = 24) being above the threshold. The rate of NH for TAR >61% versus ≤61% was 45.8 versus 25.9% (p = 0.06). Neonates born to individuals with TAR >61% were more likely to require continuous positive airway pressure after delivery and had a higher cord c-peptide level. CONCLUSION In this prospective study of laboring individuals with diabetes, intrapartum CGM TAR was associated with a higher rate of NH. KEY POINTS · CGM use in labor is feasible with a complete glucose profile in the various stages of labor.. · Best cut-off for predicting NH was a time above range (≥110 mg/dl) of >61%.. · CGM and FS were poor predictors of NH..
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Affiliation(s)
- Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarah A Nazeer
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Joycelyn Ashby Cornthwaite
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Ghamar Bitar
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Sean C Blackwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Suneet P Chauhan
- Delaware Center of Maternal-Fetal Medicine at Christiana Care, Department of Obstetrics, Gynecology, and Reproductive Sciences, Newark, Delaware
| | - Antonio Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - George Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Fishel Bartal M. Intrapartum Care for People with Diabetes-Working towards Evidence-Based Management. Am J Perinatol 2024. [PMID: 39209305 DOI: 10.1055/a-2405-1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
The consensus in the literature supports the need for careful monitoring and management of maternal blood glucose during labor to optimize neonatal outcomes. Guidelines generally recommend strict control of maternal blood glucose during labor, involving frequent checks, and the use of dextrose and insulin as needed. However, recent evidence has not consistently shown a strong association between strict control of blood glucose and a reduction in the rate of neonatal hypoglycemia. This raises questions about the extent to which intrapartum blood glucose control impacts neonatal hypoglycemia. This review aims to explore the literature on intrapartum maternal blood glucose management in individuals with pregestational or gestational diabetes, utilizing peer-reviewed journals and datasets, including PubMed, Google Scholar, and clinical guidelines. Observational studies, small sample sizes, variability in definitions of maternal hyperglycemia and neonatal hypoglycemia, and differences in measurement methods such as timing and thresholds for intervention limit the literature on this topic. Additionally, many studies may not fully account for confounding factors such as maternal body mass index, diet, and other comorbidities affecting blood glucose levels. These limitations underscore the need for a cautious interpretation of current findings and highlight the necessity for future research in this area. This review elaborates on the available data and summarizes evidence on managing labor in pregnancies complicated by diabetes. We also emphasize the need for further research to clarify the relationship between maternal blood glucose during labor and neonatal blood glucose. KEY POINTS: · The benefits of strict intrapartum blood glucose control are unclear.. · The optimal maternal blood glucose range to prevent neonatal hypoglycemia remains undefined.. · Additional research is necessary to understand the relationship between maternal and neonatal blood glucose..
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Affiliation(s)
- Michal Fishel Bartal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Ulyatt CM, Roberts LF, Crowther CA, Harding JE, Lin L. Intrapartum maternal glycaemic control for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:423. [PMID: 38872105 PMCID: PMC11170869 DOI: 10.1186/s12884-024-06615-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/31/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Neonatal hypoglycaemia is the most common metabolic disorder in infants, and may be influenced by maternal glycaemic control. This systematic review evaluated the effect of intrapartum maternal glycaemic control on neonatal hypoglycaemia. METHODS We included randomised controlled trials (RCTs), quasi-RCTs, non-randomised studies of interventions, and cohort or case-control studies that examined interventions affecting intrapartum maternal glycaemic control compared to no or less stringent control. We searched four databases and three trial registries to November 2023. Quality assessments used Cochrane Risk of Bias 1 or the Effective Public Health Practice Project Quality Assessment Tool. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Meta-analysis was performed using random-effects models analysed separately for women with or without diabetes. The review was registered prospectively on PROSPERO (CRD42022364876). RESULTS We included 46 studies of women with diabetes and five studies of women without diabetes: one RCT, 32 cohort and 18 case-control studies (11,273 participants). For women with diabetes, the RCT showed little to no difference in the incidence of neonatal hypoglycaemia between tight versus less tight intrapartum glycaemic control groups (76 infants, RR 1.00 (0.45, 2.24), p = 1.00, low certainty evidence). However, 11 cohort studies showed tight intrapartum glycaemic control may reduce neonatal hypoglycaemia (6,152 infants, OR 0.44 (0.31, 0.63), p < 0.00001, I2 = 58%, very low certainty evidence). For women without diabetes, there was insufficient evidence to determine the effect of tight intrapartum glycaemic control on neonatal hypoglycaemia. CONCLUSIONS Very uncertain evidence suggests that tight intrapartum glycaemic control may reduce neonatal hypoglycaemia in infants of women with diabetes. High-quality RCTs are required.
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Affiliation(s)
- Caitlyn M Ulyatt
- Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Lily F Roberts
- Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Caroline A Crowther
- Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Luling Lin
- Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
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Rowe CW, Rosee P, Sathiakumar A, Ramesh S, Qiao V, Huynh J, Dennien G, Weaver N, Wynne K. Factors associated with maternal hyperglycaemia and neonatal hypoglycaemia after antenatal betamethasone administration in women with diabetes in pregnancy. Diabet Med 2024; 41:e15262. [PMID: 38017692 DOI: 10.1111/dme.15262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 11/30/2023]
Abstract
AIMS Bespoke glycaemic control strategies following antenatal corticosteroids for women with diabetes in pregnancy (DIP) may mitigate hyperglycaemia. This study aims to identify predictive factors for the glycaemic response to betamethasone in a large cohort of women with DIP. METHODS Evaluation of a prospective cohort study of 347 consecutive DIP pregnancies receiving two doses of 11.4 mg betamethasone 24 h apart between 2017 and 2021 and treated with the Pregnancy-IVI intravenous insulin protocol. Regression modelling identified factors associated with maternal glycaemic time-in-range (TIR) and maternal insulin requirements following betamethasone. Factors associated with neonatal hypoglycaemia (glucose <2.6 mmol/L) in infants born within 48 h of betamethasone administration (n = 144) were investigated. RESULTS The mean maternal age was 31.9 ± 5.8 years, with gestational age at betamethasone of 33.5 ± 3.4 weeks. Gestational diabetes was present in 81% (12% type 1; 7% type 2). Pre-admission subcutaneous insulin was prescribed for 63%. On-infusion maternal glucose TIR (4.0-7.8 mmol/L) was 83% [IQR 77%-90%] and mean on-IVI glucose was 6.6 ± 0.5 mmol/L. Maternal hypoglycaemia (<3.8 mmol/L) was uncommon (0.47 h/100 on-IVI woman hours). Maternal glucose TIR was negatively associated with indicators of insulin resistance (type 2 diabetes, polycystic ovary syndrome), late-pregnancy complications (pre-eclampsia, chorioamnionitis) and the 1-h OGTT result. Intravenous insulin requirements were associated with type of diabetes, pre-eclampsia and intrauterine infection, the 1-h OGTT result and the timing of betamethasone administration. Neonatal hypoglycaemia was associated with pre-existing diabetes but not with measures of glycaemic control. CONCLUSION An intravenous infusion protocol effectively controls maternal glucose after betamethasone. A risk-factor-based approach may allow individualisation of therapy.
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Affiliation(s)
- Christopher W Rowe
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Patrick Rosee
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Angeline Sathiakumar
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Soundarya Ramesh
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Vivian Qiao
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Jason Huynh
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Georgia Dennien
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Katie Wynne
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Dancy M, Newberry DM. Call for a More Specific Diagnosis of Infant of a Diabetic Mother to Optimize Neonatal Care. J Obstet Gynecol Neonatal Nurs 2023; 52:276-285. [PMID: 37277098 DOI: 10.1016/j.jogn.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 06/07/2023] Open
Abstract
Hyperglycemia is the diagnostic feature of diabetes mellitus (DM), and during pregnancy, hyperglycemia has numerous serious implications for organogenesis and fetal growth. Each type of DM has different neonatal implications based on pathogenesis, length of disease, and comorbidities. Currently, limited attention is given to the woman's type of DM when evaluating risks for neonates. The diagnosis of infant of a diabetic mother is not sufficient because of the varying pathophysiology of diabetes classifications and associated neonatal outcomes. By expanding the diagnosis to include the woman's classification and glucose control, maternity and neonatal care providers could develop plans of care based on potential neonatal outcomes, including anticipatory guidance for families. In this commentary, we propose a more specific diagnosis, rather than infant of a diabetic mother, to better serve these infants.
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Avari P, O'Regan A, Preechasuk L, Oliver N, Agha-Jaffar R. Adjustment of Maternal Variable Rate Insulin Infusions Using Real-Time Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes. Diabetes Technol Ther 2023; 25:293-297. [PMID: 36695715 DOI: 10.1089/dia.2022.0507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Real-time continuous glucose monitoring (CGM) in hospital holds promise; however, further evidence is required on its use to guide adjustment of variable rate intravenous insulin infusion (VRIII). We retrospectively analyzed data from 20 women with type 1 diabetes during the peripartum period who were commenced on VRIII. Data were analyzed for CGM accuracy (Dexcom G6) using point-of-care glucose-CGM matched pairs. The study was entirely observational, with no deviation from standard clinical care. Twenty women were included; median age 30 (26-35) years with first glycated hemoglobin in pregnancy of 57 (49-60) mmol/mol. Overall median absolute relative difference was 6.1 (1.6-17.3)%. The total simulated CGM-adjusted VRIII was 2.5 U per hour, compared with 2.4 U per hour with capillary blood glucose-adjusted VRIII. In this retrospective analysis of CGM adjustment of maternal VRIII, we demonstrate early feasibility and considerable accuracy. Further prospective studies are required to confirm the safety and potential efficacy of CGM-based insulin titration.
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Affiliation(s)
- Parizad Avari
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Alice O'Regan
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lukana Preechasuk
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
- Siriraj Diabetes Center of Excellence, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nick Oliver
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rochan Agha-Jaffar
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
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Rowe CW, Watkins B, Brown K, Delbridge M, Addley J, Woods A, Wynne K. Efficacy and safety of the pregnancy-IVI, an intravenous insulin protocol for pregnancy, following antenatal betamethasone in type 1 and type 2 diabetes. Diabet Med 2021; 38:e14489. [PMID: 33277738 DOI: 10.1111/dme.14489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 01/26/2023]
Abstract
AIMS Hyperglycaemia following antenatal corticosteroids is common in women with diabetes in pregnancy, and validated algorithms to maintain pregnancy-specific glucose targets are lacking. The Pregnancy-IVI, an intravenous-insulin (IVI) algorithm, has been validated in gestational diabetes; however, its performance in pre-existing diabetes (Type 1 and Type 2 diabetes) is not known. We hypothesised that Pregnancy-IVI would be superior to a generic Adult-IVI protocol (prior standard of care) following betamethasone in women with pre-existing diabetes. METHODS A retrospective cohort study enrolled all women with pre-existing diabetes at a tertiary centre receiving betamethasone and treated with IVI according to one of two protocols: Adult-IVI (n = 73, 2014-2017) or Pregnancy-IVI (n = 62, 2017-2020). The primary outcome was on-IVI glycaemic time-in-range (capillary blood glucose (BGL) 3.8-7.0 mmol/L). Secondary outcomes included time with critical hyperglycaemia (BGL > 10 mmol/L); occurrence of maternal hypoglycaemia (BGL < 3.8 mmol/l) and incidence of neonatal hypoglycaemia (BGL ≤ 2.5 mmol/L). Analysis was stratified by diabetes type. RESULTS Overall, Pregnancy-IVI achieved a higher proportion of on-IVI time-in-range (70%, IQR 56-78%) compared to Adult-IVI (52%, IQR 41-69%, p < 0.0001). The duration of critical hyperglycaemia with Pregnancy-IVI was also reduced (2% [IQR 0-7] vs 8% [IQR 4-17], p < 0.0001), without an increase in hypoglycaemia. Glycaemic variability was significantly reduced with Pregnancy-IVI. No difference in the rate of neonatal hypoglycaemia was observed. The Pregnancy-IVI was most effective in women with Type 1 diabetes. CONCLUSION The Pregnancy-IVI algorithm is safe and effective when used following betamethasone in type 1 diabetes in pregnancy. Further study of women with type 2 diabetes is required.
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Affiliation(s)
- Christopher W Rowe
- Department of Diabetes and Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Brendan Watkins
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- School of Rural Medicine, University of New England, Armidale, NSW, Australia
| | - Karina Brown
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- School of Rural Medicine, University of New England, Armidale, NSW, Australia
| | - Matthew Delbridge
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- School of Rural Medicine, University of New England, Armidale, NSW, Australia
| | - Jordan Addley
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Andrew Woods
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Katie Wynne
- Department of Diabetes and Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
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Abdulla S, Divakaran M, Ramakrishnan R. Maternal obesity affecting immediate neonatal outcomes in infants of diabetic mothers: A case–control study. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_65_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kumar N, Kumar P, Harris N, Monga R, Sampath V. Impact of Maternal HbA1c Levels ≤6% and Race in Nondiabetic Pregnancies on Birthweight and Early Neonatal Hypoglycemia. J Pediatr 2020; 227:121-127.e3. [PMID: 32800816 DOI: 10.1016/j.jpeds.2020.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/25/2020] [Accepted: 08/10/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate whether pregnancy glycated hemoglobin (HbA1c) levels of ≤6% and maternal race impacts neonatal hypoglycemia and birthweight, and whether diabetes and beta blocker use during pregnancy additively impacts neonatal outcomes. STUDY DESIGN Retrospective chart review of 4769 infants born at ≥34 weeks; 21 482 glucose measurements were assessed. Predefined groups were infants born to mothers without documented pregnancy conditions (group N), prenatal exposure of beta blockers (group B), diabetes (group D), or both (group DB). RESULTS In group N, both in Caucasian (Caucasian, n = 1756; β = 2.6, P < .001) and African American (n = 1872; β = 2.2, P = .002) race, there was a direct relationship between pregnancy HbA1c levels and birthweight. HbA1c (aOR 1.8; 95% CI [1.3-2.5]) levels, maternal race, prematurity, cesarean delivery, and birth weight predicted hypoglycemia. Each 0.1% increase in HbA1c levels between 4.8 and 6 increased the odds of neonatal hypoglycemia by 6.4% in African American (β 0.62, SE 0.22, P = .01) and by 12.0% in Caucasian (β 1.13, SE 0.23 P < .001) population. The odds of neonatal hypoglycemia were 1.7 (group B), 2.1 (group D), and 3.1 (group DB) times higher compared with group N. CONCLUSIONS Pregnancy HbA1c levels between 4.8% and 6.0% considered acceptable during pregnancy impacts neonatal hypoglycemia and birthweight especially in Caucasian race. A third trimester HbA1c >5.2 is a potential risk factor for neonatal hypoglycemia, especially in preterm infants. Although we report new findings on the relationship between maternal HbA1c levels and neonatal outcomes, a prospective study is required to validate our findings and determine "optimal" HbA1C levels during pregnancy.
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Affiliation(s)
- Navin Kumar
- Division of Neonatology, Hurley Children's Hospital, Flint, MI.
| | - Parkash Kumar
- Department of Public Health, University of Michigan, Flint, MI
| | - Nathalee Harris
- Division of Neonatology, Hurley Children's Hospital, Flint, MI
| | - Ranjan Monga
- Division of Neonatology, Hurley Children's Hospital, Flint, MI
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Abstract
OBJECTIVE To examine whether an insulin protocol for intrapartum glucose control among parturients with diabetes was associated with improved outcomes. METHODS This is a retrospective cohort study of women with pregestational or gestational diabetes delivering a liveborn neonate at Northwestern Memorial Hospital. Before 2011, women with diabetes were given intravenous (IV) insulin or glucose during labor at the discretion of the on-call endocrinologist. In 2011, a standardized protocol was designed to titrate insulin and glucose infusions. Outcomes were compared between two time periods: January 2005-December 2010 (before implementation) and January 2012-December 2017 (after implementation) with 2011 excluded to account for a phase-in period. Maternal outcomes included intrapartum hyperglycemia (blood glucose greater than 125 mg/dL) and hypoglycemia (blood glucose less than 60 mg/dL). Neonatal outcomes included hypoglycemia (blood glucose less than 50 mg/dL), intensive care admission, and IV dextrose therapy. t tests, Wilcoxon rank sum tests, and χ tests were used for bivariable analyses. Linear and logistic multivariable regression were used to account for confounding factors. RESULTS Of 3,689 women, 928 (25.2%) delivered before 2011. After protocol implementation, frequencies of both maternal intrapartum hyperglycemia (51.3% vs 37.9%) and hypoglycemia decreased (6.1% vs 2.5%), both P<.001; respective adjusted odds ratio [aOR] 0.64, 95% CI 0.54-0.77 and 0.50, 95% CI 0.33-0.78. The frequency of neonatal hypoglycemia, however, increased (36.6% vs 49.2%, P<.001; aOR 1.73, 95% CI 1.45-2.07). Admission to the neonatal intensive care unit and need for IV dextrose therapy were similar across time periods. CONCLUSION A formal protocol to manage insulin and glucose infusions for parturients with diabetes was associated with improved intrapartum maternal glucose control, but an increased frequency of neonatal hypoglycemia.
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Yamamoto JM, Donovan LE, Mohammad K, Wood SL. Severe neonatal hypoglycaemia and intrapartum glycaemic control in pregnancies complicated by type 1, type 2 and gestational diabetes. Diabet Med 2020; 37:138-146. [PMID: 31529717 PMCID: PMC6916340 DOI: 10.1111/dme.14137] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2019] [Indexed: 12/30/2022]
Abstract
AIMS To determine if in-target intrapartum glucose control is associated with neonatal hypoglycaemia in women with type 1, type 2 or gestational diabetes. METHODS This was a retrospective cohort study of pregnant women with diabetes and their neonates. The primary exposure was in-target glucose control, defined as all capillary glucose values within the range 3.5-6.5 mmol/l during the intrapartum period. The primary outcome, neonatal hypoglycaemia, was defined as treatment with intravenous dextrose therapy. Multiple logistic regression was used to examine the association between maternal intrapartum glycaemic control and neonatal hypoglycaemia, adjusting for covariates. RESULTS Intrapartum glucose testing was available for 157 (86.3%), 267 (76.3%) and 3256 (52.4%) women with type 1, type 2 and gestational diabetes, respectively. In the univariate analysis, in-target glycaemic control was significantly associated with neonatal hypoglycaemia in women with gestational diabetes, but not in women with type 1 or 2 diabetes. However, after adjustment for important neonatal factors (large for gestational age, preterm delivery and infant sex), intrapartum in-target glycaemic control was not significantly associated with neonatal hypoglycaemia in women regardless of diabetes type [adjusted odds ratios 0.4 (95% CI 0.1, 1.4), 0.7 (95% CI 0.3, 1.3) and 0.7 (95% CI 0.5, 1.0) for women with type 1, type 2 and gestational diabetes, respectively]. CONCLUSIONS There was no significant association between in-target glycaemic control and neonatal hypoglycaemia after adjustment for neonatal factors. Given the high risk of maternal hypoglycaemia and the resources required, future trials should consider whether more relaxed intrapartum glycaemic targets may be safer and yield similar neonatal outcomes.
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Affiliation(s)
- J. M. Yamamoto
- Department of MedicineUniversity of CalgaryCumming School of MedicineCalgaryAlbertaCanada
- Department of Obstetrics and GynaecologyUniversity of CalgaryCumming School of MedicineCalgaryAlbertaCanada
- Alberta Children's Hospital Research InstituteCalgaryAlbertaCanada
| | - L. E. Donovan
- Department of MedicineUniversity of CalgaryCumming School of MedicineCalgaryAlbertaCanada
- Department of Obstetrics and GynaecologyUniversity of CalgaryCumming School of MedicineCalgaryAlbertaCanada
- Alberta Children's Hospital Research InstituteCalgaryAlbertaCanada
| | - K. Mohammad
- Section of NeonatologyDepartment of PaediatricsCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - S. L. Wood
- Department of Obstetrics and GynaecologyUniversity of CalgaryCumming School of MedicineCalgaryAlbertaCanada
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Yamamoto JM, Corcoy R, Donovan LE, Stewart ZA, Tomlinson G, Beardsall K, Feig DS, Murphy HR. Maternal glycaemic control and risk of neonatal hypoglycaemia in Type 1 diabetes pregnancy: a secondary analysis of the CONCEPTT trial. Diabet Med 2019; 36:1046-1053. [PMID: 31107983 DOI: 10.1111/dme.13988] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 11/27/2022]
Abstract
AIMS To examine the relationship between maternal glycaemic control and risk of neonatal hypoglycaemia using conventional and continuous glucose monitoring metrics in the Continuous Glucose Monitoring in Type 1 Diabetes Pregnancy Trial (CONCEPTT) participants. METHODS A secondary analysis of CONCEPTT involving 225 pregnant women and their liveborn infants. Antenatal glycaemia was assessed at 12, 24 and 34 weeks gestation. Intrapartum glycaemia was assessed by continuous glucose monitoring measures 24 hours prior to delivery. The primary outcome was neonatal hypoglycaemia defined as glucose concentration < 2.6 mmol/l and requiring intravenous dextrose. RESULTS Neonatal hypoglycaemia occurred in 57/225 (25.3%) infants, 21 (15%) term and 36 (40%) preterm neonates. During the second and third trimesters, mothers of infants with neonatal hypoglycaemia had higher HbA1c [48 ± 7 (6.6 ± 0.6) vs. 45 ± 7 (6.2 ± 0.6); P = 0.0009 and 50 ± 7 (6.7 ± 0.6) vs. 46 ± 7 (6.3 ± 0.6); P = 0.0001] and lower continuous glucose monitoring time-in-range (46% vs. 53%; P = 0.004 and 60% vs. 66%; P = 0.03). Neonates with hypoglycaemia had higher cord blood C-peptide concentrations [1416 (834, 2757) vs. 662 (417, 1086) pmol/l; P < 0.00001], birthweight > 97.7th centile (63% vs. 34%; P < 0.0001) and skinfold thickness (P ≤ 0.02). Intrapartum continuous glucose monitoring was available for 33 participants, with no differences between mothers of neonates with and without hypoglycaemia. CONCLUSIONS Modest increments in continuous glucose monitoring time-in-target (5-7% increase) during the second and third trimesters are associated with reduced risk for neonatal hypoglycaemia. While more intrapartum continuous glucose monitoring data are needed, the higher birthweight and skinfold measures associated with neonatal hypoglycaemia suggest that risk is related to fetal hyperinsulinemia preceding the immediate intrapartum period.
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Affiliation(s)
- J M Yamamoto
- Departments of Medicine and Obstetrics and Gynaecology, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, Calgary, Canada
| | - R Corcoy
- Servei d'Endocrinologia i Nutrició, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBER-BBN, Madrid, Spain
| | - L E Donovan
- Departments of Medicine and Obstetrics and Gynaecology, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, Calgary, Canada
| | - Z A Stewart
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Cardiovascular Sciences, University of Leicester, UK
| | - G Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - K Beardsall
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Neonatal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D S Feig
- Department of Medicine, University of Toronto, Toronto, Canada
- Mount Sinai Hospital, Sinai Health System, Toronto, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | - H R Murphy
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Women's Health Academic Centre, Division of Women's and Children's Health, King's College London, London, UK
- Norwich Medical School, Floor 2, Bob Champion Research and Education Building, James Watson Road, University of East Anglia, Norwich Research Park, Norwich, UK
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Rowe CW, Putt E, Brentnall O, Gebuehr A, Allabyrne J, Woods A, Wynne K. An intravenous insulin protocol designed for pregnancy reduces neonatal hypoglycaemia following betamethasone administration in women with gestational diabetes. Diabet Med 2019; 36:228-236. [PMID: 30443983 DOI: 10.1111/dme.13864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2018] [Indexed: 11/29/2022]
Abstract
AIMS Marked hyperglycaemia is common following betamethasone administration in women with gestational diabetes (GDM), and may contribute to neonatal hypoglycaemia. Validated protocols to deliver glycaemic stability following betamethasone are lacking. We hypothesized that an intravenous insulin (IVI) protocol for pregnancy-specific glycaemic targets (Pregnancy-IVI) would achieve greater at-target glycaemic control than a generic adult intravenous insulin protocol (Adult-IVI), and may reduce neonatal hypoglycaemia. METHODS A retrospective cohort study of the performance Adult-IVI and Pregnancy-IVI following betamethasone in GDM, sequentially implemented at a tertiary hospital, without change in indication for IVI. Cases were identified by electronic record search. Primary outcome was percentage of on-IVI time with at-target glycaemia [blood glucose level (BGL) 3.8-7 mmol/l]. Secondary outcomes were time with critical hyperglycaemia (BGL > 10 mmol/l), occurrence of maternal hypoglycaemia (BGL < 3.8 mmol/l), and incidence of neonatal hypoglycaemia (BGL ≤ 2.5 mmol/l) if betamethasone was administered within 48 h of birth. RESULTS The cohorts comprised 151 women (Adult-IVI n = 86; Pregnancy-IVI n = 65). The primary outcome was 68% time-at-target [95% confidence interval (CI) 64-71%) for Pregnancy-IVI compared with 55% (95% CI 50-60%) for Adult-IVI (P = 0.0002). Critical maternal hyperglycaemia (0% vs. 2%, P = 0.02) and hypoglycaemia (2% vs. 12%, P = 0.02) were both lower with Pregnancy-IVI than Adult-IVI. Neonatal hypoglycaemia was less common after Pregnancy-IVI (29%) than after Adult-IVI (54%, P = 0.03). A multiple logistic regression model adjusting for potential confounders gave an odds ratio for neonatal hypoglycaemia with Pregnancy-IVI of 0.27 (95% CI 0.10-0.76, P = 0.01). CONCLUSIONS An IVI protocol designed for pregnancy effectively controlled maternal hyperglycaemia following betamethasone administration in GDM. This is the first intervention to show a reduction in betamethasone-associated neonatal hypoglycaemia, linked with optimum maternal glycaemic control.
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Affiliation(s)
- C W Rowe
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, Australia
- School of Medicine and Public Health, University of New castle, Newcastle, Australia
| | - E Putt
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, Australia
| | - O Brentnall
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, Australia
| | - A Gebuehr
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, Australia
| | - J Allabyrne
- Department of Maternity and Gynaecology, John Hunter Hospital, Newcastle, Australia
| | - A Woods
- School of Medicine and Public Health, University of New castle, Newcastle, Australia
- Department of Maternity and Gynaecology, John Hunter Hospital, Newcastle, Australia
| | - K Wynne
- Department of Endocrinology and Diabetes, John Hunter Hospital, Newcastle, Australia
- School of Medicine and Public Health, University of New castle, Newcastle, Australia
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Armengaud JB, Ma RCW, Siddeek B, Visser GHA, Simeoni U. Offspring of mothers with hyperglycaemia in pregnancy: The short term and long-term impact. What is new? Diabetes Res Clin Pract 2018; 145:155-166. [PMID: 30092235 DOI: 10.1016/j.diabres.2018.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/30/2018] [Indexed: 12/20/2022]
Abstract
The continuing rise in the global prevalence of diabetes and overweight or obesity has become a major burden for global health, as the pandemic is affecting both high and low-middle income countries (LMIC). At the same time, a similar pattern has been observed for all forms of hyperglycemia in pregnancy (HIP), diabetes during pregnancy and gestational diabetes. The offspring of mothers with HIP and/or overweight-obesity is receiving increasing attention as advances in early detection and treatment of HIP did not completely prevent macrosomia and its associated short-term perinatal disorders, whilst long term consequences are observed in the mother and in offspring as it reaches adulthood. This review discusses the current developments in the consequences of HIP in the offspring, with a particular focus on its long-term health at adulthood, and on intergenerational and transgenerational effects. HIP is emerging as one of the factors that can contribute, during the window of sensitivity to environmental cues constituted by the preconception, pregnancy, and early childhood, and as an amplifying factor linked to reproduction, to the current global epidemic of diabetes and non-communicable diseases (NCDs).
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Affiliation(s)
- Jean-Baptiste Armengaud
- Woman-Mother-Child Department, Division of Pediatrics, Centre Hospitalier Universitaire Vaudois, DOHaD Laboratory, University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong.
| | - Benazir Siddeek
- Woman-Mother-Child Department, Division of Pediatrics, Centre Hospitalier Universitaire Vaudois, DOHaD Laboratory, University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center Utrecht, The Netherlands
| | - Umberto Simeoni
- Division of Pediatrics and DOHaD Lab, CHUV University Hospital & FBM, University of Lausanne, Rue du Bugnon 46, 1011 Lausanne CH, Switzerland.
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