Parity Increases Insulin Requirements in Pregnant Women With Type 1 Diabetes

Comparative analysis of perinatal outcomes in pregnant women with pregestational diabetes mellitus based on diagnostic timing

Diabetes is a major concern in healthcare worldwide and is detrimental to mothers and fetuses during pregnancy. However, half of the women were unaware of hyperglycemia before pregnancy, and there is no consensus on their identification during pregnancy. We aim to understand the role that diagnostic timing plays in perinatal outcomes. This was a multicenter retrospective study of all pregestational diabetes mellitus (PGDM) women who delivered from January 2021 to June 2023. Diagnoses were made before or during gestation. Characteristics and outcomes were compared among stages, and logistic regression was performed to explore the relationship between adverse outcomes and the diagnostic timing. This study included 2,818 women; 1188 (42.2%) were self-aware before pregnancy, and 286 (10.1%), 1208 (42.9%), and 136 (4.8%) were diagnosed in the first, second, and third trimesters, respectively. Maternal body mass index, hypertensive disorders during pregnancy, glucose profile, large-for-gestational-age (LGA), etc., differed among stages (all P < 0.05). Logistic regression revealed that PGDM diagnosed during any trimester was significantly associated with an increased risk of macrosomia (aOR = 2.632, 1.502, 2.314; all P < 0.05). However, the risk of LGA decreased if the diagnosis was based on the 2 h value of the oral glucose tolerance test (OGTT) alone in the second trimester (aOR = 0.608, 95% CI: 0.444-0.831). No relationship existed between diagnostic timing and neonatal birth defects or hypoglycemia (both P > 0.05). PGDM identified during pregnancy was significantly associated with an increased risk of fetal overgrowth. The role of the 2 h-OGTT alone in diagnosis warrants further exploration. PGDM screening is essential for the entire gestational period.

Sensor-derived glycaemic metrics in pregnant women with type 1 diabetes randomised to faster acting insulin aspart or insulin aspart-A secondary analysis of the CopenFast trial

AIMS

We compared sensor-derived glycaemic metrics in pregnant women with type 1 diabetes (T1D) randomised to faster acting insulin aspart (faster aspart) or insulin aspart (IAsp).

METHODS

A pre-planned secondary analysis of the CopenFast trial included women with T1D using intermittently scanned continuous glucose monitoring (isCGM) during pregnancy. Glycaemic metrics, including time in range (TIRp, 3.5-7.8 mmol/L) and time below range in pregnancy (TBRp, <3.5 mmol/L), were evaluated in the intervals: from randomisation (median 9.5 weeks, interquartile range 9.0-11.0) to 21 weeks, from 22 to 33 weeks and from 34 to 37 weeks.

RESULTS

In total, 113 (91%) of 124 women using isCGM in the original trial were included. At randomisation, glycaemic metrics were comparable in both groups. Women randomised to faster aspart achieved higher TIRp from 22 to 33 weeks (estimated treatment difference 5.1% [95% confidence interval 0.3; 9.7], p = 0.04) and mean TIRp >70% from randomisation to 21 weeks onwards, while this was achieved after 34 weeks in women randomised to IAsp. TBRp remained stable around 4% throughout pregnancy in both groups. One (2%) versus 5 (9%) experienced ≥1 severe hypoglycaemic event (odds ratio 0.93 [-0.2; -0.01], p = 0.04). Infant birthweight standard deviation score was lower in the faster aspart group (estimated treatment difference -0.5 [-0.9; -0.03], p = 0.04); however, this attenuated when adjusting for parity (p = 0.10).

CONCLUSIONS

Women using faster aspart achieved more TIRp and experienced less severe hypoglycaemia compared to women using IAsp. Infant birthweight was lower and thereby more appropriate in the faster aspart group; however, this attenuated when adjusting for parity.

Fetal sex effects on maternal health can now be tested via randomization: A first-in-class illustration in cows on glucoregulatory outcomes

BACKGROUND

The maternal-offspring relationship, such as whether fetal sex influences maternal health, is essential to explore to advance prenatal and maternal health. While associations exist between fetal sex and maternal health outcomes, it is unclear whether these reflect a causal relationship.

OBJECTIVE

To demonstrate that fetal sex can be randomly assigned to test the causal effect of fetal sex on maternal outcomes.

METHODS

Holstein dairy cows were stratified and randomized using sealed opaque envelopes to be artificially inseminated with either X- or Y-sorted bull semen until 40 cows became pregnant. Monthly body weight measurements were recorded, and an intravenous glucose tolerance test was performed 30 days before the expected calving day. The primary outcome was insulin area under the curve (AUC), and secondary outcomes were clearance rate, half-life, and AUC for glucose, insulin, and non-esterified fatty acid concentrations. An intention-to-treat (ITT) approach using multiple imputation was employed for primary analysis, and an as-treated (AT) approach was used for secondary analysis.

RESULTS

We demonstrated that we could successfully randomize the assignment of fetal sex to dams and test for causal effects of fetal sex on glucoregulatory outcomes using dairy cows as a model. Insulin AUC was not statistically different between groups (ITT p = 0.857, AT p = 0.874), and other outcomes were also not statistically different (p > 0.05).

CONCLUSION

We demonstrated that causal effects of fetal sex on maternal outcomes can be causally tested in dairy cows. Our study did not provide statistical evidence to support an effect of fetal sex on maternal glucose-related outcomes.

Impact of Preeclampsia and Parity on Sex-based Discrepancies in Subclinical Carotid Atherosclerosis in Type 1 Diabetes

CONTEXT

The excess risk of fatal and nonfatal cardiovascular events is roughly twice as high in women than in men with type 1 diabetes.

OBJECTIVE

To evaluate the impact of preeclampsia and parity on sex-based discrepancies in preclinical atherosclerosis and on the diagnostic performance of a cardiovascular risk scale.

DESIGN

Cross-sectional study.

SETTING

Single tertiary hospital.

PATIENTS

A total of 728 people with type 1 diabetes (48.5% women) without cardiovascular disease and age ≥40 years, nephropathy, and/or ≥10 years of diabetes duration with another risk factor.

INTERVENTION

Standardized carotid ultrasonography.

MAIN OUTCOME MEASURES

Carotid plaque determined by ultrasonography and cardiovascular risk estimated according to the Steno T1 Risk Engine (Steno-Risk).

RESULTS

Nulliparous women and parous women without previous preeclampsia had a lower risk for carotid plaque than men (adjusted odds ratio: .48, 95% confidence interval [.28-.82]; adjusted odds ratio: .51 [.33-.79], respectively), without differences in the preeclampsia group. The prevalence of carotid plaque increased as the estimated cardiovascular risk increased in all subgroups except for preeclampsia group. The area under the curve of the Steno-Risk for identifying ≥2 carotid plaques was lower in the preeclampsia group (men: .7886; nulliparous women: .9026; women without preeclampsia: .8230; preeclampsia group: .7841; P between groups = .042). Neither the addition of parity nor preeclampsia in the Steno-Risk led to a statistically significant increase in the area under the curve.

CONCLUSION

The risk for carotid plaque in women compared with men decreased as exposure to obstetric factors diminished. However, the addition of these factors did not improve the prediction of the Steno-Risk.

Hormonal regulation in diabetes: Special emphasis on sex hormones and metabolic traits

Diabetes constitutes a significant global public health challenge that is rapidly reaching epidemic proportions. Among the non-communicable diseases, the incidence of diabetes is rising at an alarming rate. The International Diabetes Federation has documented a 9.09% prevalence of diabetes among individuals aged between 20 and 79 years. The interplay of gonadal hormones and gender differences is critical in regulating insulin sensitivity and glucose tolerance, and this dynamic is particularly crucial because of the escalating incidence of diabetes. Variations in insulin sensitivity are observed across genders, levels of adiposity, and age groups. Both estrogen and testosterone are seen to influence glucose metabolism and insulin sensitivity. This chapter surveys the present knowledge of sex differences, sex hormones, and chromosomes on insulin imbalance and diabetes development. It further highlights the influence of metabolic traits in diabetes and changes in sex hormones during diabetic pregnancy. Notably, even stressful lifestyles have been acknowledged to induce hormonal imbalances. Furthermore, it discusses the potential of hormonal therapy to help stabilize sex hormones in diabetic individuals and focuses on the most recent research investigating the correlation between sex hormones and diabetes.

Association of Parity With Insulin Resistance Early in Pregnant Women: ECLIPSES Study

CONTEXT

Little is known about whether parity is associated with elevated early-pregnancy insulin resistance (IR), or whether overweight/obesity contributes to increasing the possible effect.

OBJECTIVE

We determined the associations between parity and glucose metabolism parameters in the first trimester of pregnancy in a Mediterranean pregnant population, and whether these associations are affected by overweight/obesity.

METHODS

A cross-sectional study was conducted of 264 healthy pregnant women from the ECLIPSES study who were recruited at 12 weeks of gestation. At baseline, details on socioeconomic status, obstetric history (including parity, ie, number of births), lifestyle factors, anthropometry, and blood samples were collected. Fasting serum glucose, insulin, and homeostasis model assessment of insulin resistance (HOMA-IR) index were assessed in the first trimester. Elevated IR was defined as the upper HOMA-IR tertile (≥1.58). Multivariable linear regression and Cox regression model with constant time were performed.

RESULTS

Parity ranged from 0 to 4. After multivariable adjustment, the insulin levels (β [% change]: 20.92; 95% CI, 4.08-37.71) and HOMA-IR index (β [% change]: 19.72; 95% CI, 2.43-40.49) were positively associated with parity. Additionally, multiparous women, as compared to nulliparous, were more likely to have higher HOMA-IR levels (primiparous [1 birth], β [% change[: 16.88; 95% CI, -1.00 to 37.99; multiparous [≥2 births), β [% change]: 32.18; 95% CI, 3.56-68.71), and an increased relative risk (RR) of an elevated IR (primiparous [1 birth], RR: 1.55; 95% CI, 1.03-2.36; multiparous (≥2 births), RR: 1.72; 95% CI, 1.05-2.83). The combination of multiparity and overweight/obesity conferred a 3.04-fold increase in the RR of elevated IR, which increased proportionally to the number of parities.

CONCLUSION

This study demonstrates that parity may have a negative effect on early-pregnancy IR and that maternal overweight/obesity appears to further aggravate this relationship.

The physiological basis with uterine myometrium contractions from electro-mechanical/hormonal myofibril function to the term and preterm labor

Background

Most labor-related problems can be attributed to the uterine myometrium muscle, as this irritable tissue must suppress its irritability potential during pregnancy. Unfortunately, fewer studies have investigated the causes of this lack of suppression in preterm labor.

Methods

We conducted a scoping narrative review using three online databases (PubMed, Scopus, and Science Direct).

Results

The review focused on ion channel functions in the myometrium, including sodium channels [Na K-ATPase, Na-activated K channels (Slo2), voltage-gated (SCN) Na+, Na+ leaky channels, nonselective (NALCN) channels], potassium channels [KATP (Kir6) channels, voltage-dependent K channels (Kv4, Kv7, and Kv11), twin-pore domain K channels (TASK, TREK), inward rectifier Kir7.1, Ca2+-activated K+ channels with large (KCNMA1, Slo1), small (KCNN1-3), intermediate (KCNN4) conductance], and calcium channels [L-Type and T-type Ca2+ channels, calcium-activated chloride channels (CaCC)], as well as hyperpolarization-activated cation channels. These channels' functions are associated with hormonal effects such as oxytocin, estrogen/progesterone, and local prostaglandins.

Conclusion

Electromechanical/hormonal activity and environmental autocrine factors can serve as the primary practical basis for premature uterine contractions in term/preterm labor. Our findings highlight the significance of.1.the amplitude rate of hyperpolarization and the frequency of contractions,2.changes in the estrogen/progesterone ratio,3.Prostaglandins E/F involvement in initiating potential spikes and the increase of intracytoplasmic Ca2+.This narrative study highlights the range of hyperpolarization and the frequency of myometrium contractions as crucial factors. The synchronized complex progress of estrogen to progesterone ratio and prostaglandins plays a significant role in initiating potential spikes and increasing intracytoplasmic Ca2+, which further influences the contraction process during labor. Insights into myometrium physiology gained from this study may pave the way for much-needed new treatments to reduce problems associated with normal and preterm labor.

Breastfeeding and insulin requirements in women with Type 1 diabetes mellitus in the first year postpartum

AIMS

To explore whether breastfeeding affects postpartum insulin requirements, HbA1c levels, and pregnancy weight retention in women with Type 1 Diabetes Mellitus (T1DM).

METHODS

This prospective study included 66 women with T1DM. The women were divided into two groups based on whether they were breastfeeding (BF) at 6 months postpartum (BF_yes, n = 32) or not (BF_no, n = 34). Mean daily insulin requirement (MDIR), HbA1c levels, and pregnancy weight retention at 5 time-points from discharge to 12 months postpartum were compared.

RESULTS

MDIR increased by 35% from 35.7 IU at discharge to 48.1 IU at 12 months postpartum (p < 0.001). MDIR in BF_yes and BF_no were comparable, however in BF_yes, MDIR were continuously lower compared to BF_no. Postpartum HbA1c increased rapidly from 6.8% at 1 month to 7.4% at 3 months postpartum and settled at 7.5% at 12 months postpartum. The increase in HbA1c during the first 3 months postpartum was most pronounced in BF_no (p < 0.001). Although neither were statistically significant, from 3 months postpartum HbA1c levels were highest in the BF_no and BF_no had a higher pregnancy weight retention compared to BF_yes (p = 0.31).

CONCLUSION

In women with T1DM, breastfeeding did not significantly affect postpartum insulin requirements, HbA1c levels or pregnancy weight retention in the first year after delivery.

Hyperglycemia in Pregnancy and Women's Health in the 21st Century

Hyperglycemia is the commonest medical condition affecting pregnancy and its incidence is increasing globally in parallel with the twin epidemics of diabetes and obesity. Both pre-pregnancy diabetes and gestational diabetes are associated with short term pregnancy complications, with the risk of immediate complications generally broadly rising with more severe hyperglycemia. In this article we firstly consider these risks and their optimal management during pregnancy and then broaden our scope to consider the long-term implications of hyperglycemia in pregnancy as it relates to overall maternal and offspring health in a life course perspective.

Falling Insulin Requirement in Pregnant Women With Diabetes Delivering Preterm: Prevalence, Predictors, and Consequences

CONTEXT

Falling insulin requirements often lead to considerations of whether a pregnancy can continue safely or if delivery is indicated.

OBJECTIVE

To evaluate prevalence and predictors of falling insulin requirements in pregnant women with preexisting diabetes delivering preterm and to explore the relationship to fetal asphyxia and neonatal morbidity.

METHODS

A prospective cohort study of 101 consecutive singleton pregnant women with preexisting diabetes delivering preterm < 37 weeks (68 type 1 and 33 type 2 diabetes) where the prevalence of falling insulin requirements (≥20%) before delivery was recorded.

RESULTS

In total, 27% (27/101) experienced falling insulin requirements of median 30% (interquartile range 24-40) before delivery. In all women with type 1 diabetes, the prevalence was 37% (25/68), whereas it was 43% (24/56) in those with indicated preterm delivery and 6% (2/33) among women with type 2 diabetes. In women with type 1 diabetes and indicated preterm delivery, falling insulin requirements were first identified at 34 + 5 (33 + 6-35 + 4) weeks + days and delivery occurred 3 (1-9) days later. Gestational age at delivery, prevalence of suspected fetal asphyxia, and neonatal morbidity were similar in women with and without falling insulin requirements. Neither glycemic control, nausea, or preeclampsia was associated with falling insulin requirement.

CONCLUSION

Falling insulin requirements often preceded preterm delivery in women with type 1 diabetes, foremost when preterm delivery was indicated, but was not related to fetal asphyxia or neonatal morbidity. Whether falling insulin requirements in late pregnancy are a warning sign of placental insufficiency or mainly reflects variations in normal physiology needs further investigation.

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.

"High prepregnancy HbA1c is challenging to improve and affects insulin requirements, gestational length, and birthweight"

BACKGROUND

The aim of this study was to explore how prepregnancy glycosylated hemoglobin (HbA1c) affects the course of HbA1c and insulin requirements during pregnancy, the gestational length, and birthweight.

METHODS

An observational cohort study was conducted consisting of 380 women with type 1 diabetes who gave birth 530 times from 2004 to 2014. The participants were divided into four groups according to prepregnancy HbA1c.

RESULTS

HbA1c was significantly different between the groups at all time intervals from week 5 to 10 to week 33 to 36 (P ≤ .01). In group 1, with the lowest prepregnancy HbA1c (<6.5% [48 mmol/mol]), HbA1c stayed at the same level throughout pregnancy. In the other groups (group 2: 6.5% [48 mmol/mol]-7.9% [63 mmol/mol], group 3: 8% [64 mmol/mol]-9.9% [86 mmol/mol], and group 4: > 10% [86 mmol/mol]) a decrease in HbA1c was seen in early pregnancy but stabilized from midpregnancy onward. Group 1 had the lowest daily insulin requirements throughout pregnancy among the four groups (P = .001). The relationship between birthweight and prepregnancy HbA1c was found to be inversely U-shaped. Mean gestational length in group 4 was significantly shorter than in group 1 (P = .001).

CONCLUSIONS

In this very large cohort, we found that a poor prepregnancy HbA1c is a predictor for poor glycemic control during pregnancy and that HbA1c decreases until midpregnancy and then plateaus. A very poor prepregnancy HbA1c is associated with shorter gestational length and lower birthweight, which is contrary to the common assumption that poor glycemic control leads to higher birthweight.

Trends of changes in the specific contribution of selected risk factors for shoulder dystocia over a period of more than two decades

Objectives Shoulder dystocia (SD) is an obstetrical emergency with well-recognized risk factors. We aimed to identify trends of changes in the specific contribution of risk factors for SD over time. Methods A nested case control study comparing all singleton deliveries with and without SD was undertaken. A multivariable logistic regression model was used in order to identify independent risk factors for SD and a comparison of the prevalence and the specific contribution (odds ratio (OR)) of the chosen risk factors in three consecutive eight-year intervals from 1988 to 2014 was performed. Results During the study period, there were 295,946 deliveries. Of them 514 (0.174%) were complicated with SD. Between 1988 and 2014 the incidence of SD has decreased from 0.3% in 1988 to 0.1% in 2014. Using a logistic regression model grandmultiparity, diabetes mellitus (DM), fetal weight, and large for gestational age (LGA) were found to be independent risk factors for SD (OR 1.25 95% CI 1.04-1.51, p=0.02; OR 1.53 95% CI 1.19-1.97, p=0.001; OR 1.002 95% CI 1.001-1.002, p < 0.001; OR 3.88 95% CI 3.09-4.87, p < 0.001; respectively). While the OR for grandmultiparity, fetal weight, and LGA has significantly changed during the study period with a mixed trend, the OR of DM has demonstrated a significant linear increase over time. Conclusions The individual contribution of selected risk factors for the occurrence of SD has significantly changed throughout the years. The contribution of DM has demonstrated a linear increase over time, emphasizing the great impact of DM on SD.

Relationship between parity and the problems that appear in the postpartum period

Parity is associated with the incidence of problems in pregnancy, delivery and the puerperium. The influence of parity in the postpartum period has been poorly studied and the results are incongruous. The objective of this study was to identify the association between parity and the existence of distinct discomfort and problems during the postpartum period. Cross-sectional study with puerperal women in Spain. Data was collected on demographic and obstetric variables and maternal manifestations of discomfort and problems during the postpartum period. An ad hoc online questionnaire was used. Crude odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were estimated by conditional logistic regression. 1503 primiparous and 1487 multiparous participated in the study. 53.4% (803) of the primiparous women affirmed to have feelings of sadness, as opposed to 36.2% (539) of multiparous women (aOR: 1.60; 95% CI: 1.35-1.89). 48.3% (726) of primiparous had lactation problems vs 24.7% (367) of multiparous (aOR: 2.46; 95% CI: 2.05-2.94). 37.2% (559) of primiparous reported anxiety, while the percentage in multiparous was 25.7% (382) (aOR: 1.34; 95% CI: 1.12-1.61). 22.2% (333) of primiparous had depressive symptoms, and 11.6% (172) of multiparous (aOR: 1.65; CI 95%: 1.31-2.06). Faecal incontinence was more present in primiparous than in multiparous, 6.5% (97) and 3.3% (49) respectively (aOR: 1.60; 95% CI: 1.07-2.38). Parity is associated with the presence of certain problems in the postpartum period. Thus, primiparous are more likely to have lactation problems, depressive symptoms, anxiety, sadness, and faecal incontinence.

Management of Preexisting Diabetes in Pregnancy: A Review

IMPORTANCE

The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes.

OBSERVATIONS

Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated.

CONCLUSIONS AND RELEVANCE

Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.

Determinants of Maternal Insulin Resistance during Pregnancy: An Updated Overview

Insulin resistance changes over time during pregnancy, and in the last half of the pregnancy, insulin resistance increases considerably and can become severe, especially in women with gestational diabetes and type 2 diabetes. Numerous factors such as placental hormones, obesity, inactivity, an unhealthy diet, and genetic and epigenetic contributions influence insulin resistance in pregnancy, but the causal mechanisms are complex and still not completely elucidated. In this review, we strive to give an overview of the many components that have been ascribed to contribute to the insulin resistance in pregnancy. Knowledge about the causes and consequences of insulin resistance is of extreme importance in order to establish the best possible treatment during pregnancy as severe insulin resistance can result in metabolic dysfunction in both mother and offspring on a short as well as long-term basis.