Maternal and neonatal glycaemic control after antenatal corticosteroid administration in women with diabetes in pregnancy: A retrospective cohort study

Proactive Insulin Escalation for Antenatal Betamethasone-Induced Hyperglycaemia in Women With Diabetes: A Prospective Cohort Study

BACKGROUND

In patients with diabetes, antenatal glucocorticoids can induce transient maternal hyperglycaemia for approximately 72 h. This may be associated with adverse outcomes, including neonatal hypoglycaemia, prompting recommendations for prophylactic increases in insulin by some expert groups; however, there are no validated protocols. A review of our institutional practice of empiric dose escalation (Day 1:25%, Day 2-3:40%, Day 4:20%, Day 5:10%) determined it was inadequate to prevent hyperglycaemia.

AIM

To investigate the efficacy of an intensified insulin escalation protocol in achieving time in target range (3.9-7.8 mmol/L) following antenatal betamethasone.

MATERIALS AND METHODS

Following implementation of the intensified insulin escalation protocol at Western Health (Day 1 and 2: 50% increase, Day 3:30% increase), a prospective cohort study was conducted for women with gestational diabetes or type 2 diabetes managed with insulin requiring betamethasone. Data was collected from the electronic medical record and expressed as mean ± SD or median (IQR).

RESULTS

29 women (82.8% GDM, 17.2% T2DM) were included with median gestation 33 + 2 (31-34+4) weeks and median BMI 30 kg/m2 (27-38IQR). In the 72 h post first-dose betamethasone, the proportion of readings in target range (< 5.1 mmol/L fasting and < 6.8 mmol/L post prandial) was 35.3%. There was no maternal hypoglycaemia. Median increase in insulin requirement was 50% (22.6%-100% IQR) on Day 1, 106% on Day 2 (33%-297% IQR) and 133% on Day 3 (23%-543% IQR).

CONCLUSIONS

A significant increase in insulin requirement, exceeding current guideline recommendations, occurs following antenatal betamethasone in women with diabetes, and further prospective evaluation of optimal dosing is required.

A short-course of low-dose insulin detemir effectively decreases blood glucose levels in gestational diabetic women undergoing dexamethasone treatment to promote newborn lung maturity

Pregnant women with gestational diabetes mellitus undergoing glucocorticoid treatment to prevent neonatal respiratory distress syndrome could have increased glucose level. We performed a retrospective study and reviewed gestational diabetic women who received an intramuscular dexamethasone injection (6 mg, every 12 hours, 4 times) in our hospital between December 2018 and June 2020. Eligible pregnant women were assigned to the study group (with simultaneous subcutaneous insulin detemir injection, 2-4 units per day) or the control group (without insulin detemir injection). The fasting and 2-hour postprandial blood glucose levels were measured before and on days 1, 2, and 3 after the insulin detemir injection. The changes in their blood glucose levels were compared before and after the drug administrations as well as between the 2 groups. A total of 104 pregnant women were analyzed, including 48 women in the study group and 56 women in the control group. The blood glucose levels increased, with the peak levels occurring on the next day, after the dexamethasone administration in both groups. Compared with the control group, the study group had lower 2-hour postprandial blood glucose levels on days 2 and 3 after the insulin detemir injection (P < .05). There were no statistically significant differences in the fasting blood glucose levels between the 2 groups. Dexamethasone administration increased the blood glucose levels in the pregnant women with gestational diabetes mellitus. A short-course of low-dose insulin detemir administration effectively lowered the blood glucose levels in these women.

Maternal and neonatal outcomes following antenatal corticosteroids in pregnancies complicated by diabetes: a scoping review

Objective

To examine the current literature surrounding the administration of antenatal corticosteroids in pregnancies complicated by diabetes and summarize the reported neonatal and maternal outcomes in exposed and unexposed groups.

Data sources

A systematic search was performed in November 2023 using Ovid Medline and Embase databases to identify relevant studies.

Study Eligibility Criteria

Articles that reported on the maternal or neonatal outcomes in pregnancies complicated by pre-gestational or gestational diabetes after exposure to antenatal corticosteroids were included in this review. Articles were excluded if they did not separately report on the outcomes experienced by women with diabetes.

Methods

Maternal and neonatal outcomes of interest included neonatal respiratory distress syndrome, neonatal hypoglycemia, and maternal hyperglycemia. Key words in this search included combinations of the terms related to pre-gestational and gestational diabetes, antenatal corticosteroids, respiratory distress syndrome, hypoglycemia, and hyperglycemia. Title and abstract screening was conducted in duplicate.

Results

There were 19 studies that met the inclusion criteria. There were 13 studies that presented results pertaining to neonatal respiratory distress syndrome, 14 studies discussed neonatal hypoglycemia and 5 studies discussed maternal hyperglycemia. Only 2 included studies were randomized controlled trials with the remaining 17 studies being observational. There was heterogeneity in clinical settings, study populations, type of corticosteroid administered and timing of administration across the included studies. This review found that there is no clear evidence of beneficial effect of corticosteroid administration on neonatal respiratory outcomes in pregnancies complicated by diabetes. Additionally, there was discrepancy between studies reporting on neonatal hypoglycemia with 6 studies reporting an increased incidence in this outcome after antenatal corticosteroid exposure whilst 4 studies found no difference between exposed and unexposed groups. This review identified a specific gap in the reporting of maternal hyperglycemia following antenatal corticosteroids. The limited number of studies that did report this outcome unanimously reported an increased incidence of maternal hyperglycemia after corticosteroid exposure. The majority of studies had small sample sizes of pregnancies both complicated by diabetes and exposed to corticosteroids and therefore lacked sufficient power to make robust conclusions about the influence of antenatal corticosteroids in this group.

Conclusion

This review concludes that there are insufficient data regarding the risks and benefits of antenatal corticosteroid administration in pregnancies complicated by diabetes.

Non-Pharmacological Management of Gestational Diabetes Mellitus with a High Fasting Glycemic Parameter: A Hospital-Based Study in Vietnam

Background/Objectives: The prevalence of gestational diabetes mellitus (GDM) is increasing at an alarming rate worldwide. Delayed management can lead to adverse composite outcomes for both mother and her offspring. To our knowledge, the clinical association between glycemic parameters and the results of the non-pharmacological GDM approach remains limited; thus, this study aimed to address this important clinical issue in the literature. Methods: This was a retrospective cross-sectional study of 174 Vietnamese pregnant women with the positive oral glucose tolerance test (OGTT) for a high fasting glycemic parameter at Hung Vuong Hospital from 04/2022 to 07/2022. This study aimed to evaluate the success rate of GDM with an elevated index of fasting glycemic concentration which was managed after 2 weeks of a dietary regimen combined with adequate physical activities and to reveal its related factors. Results: Out of 174 singleton pregnancies that met the inclusion criteria, 103 GDM pregnant women were successfully managed after 2 weeks of monitoring (59.2%; 95% confidence intervals (CI): 51.9-66.5). The study revealed a fair correlation between the corresponding test of blood glucose at OGTT and after 2 weeks of GDM management (r = 0.270-0.290, p < 0.0001). The GDM pregnant women with an elevated fasting glycemic parameter and with any of elevated 1 h or 2 h blood glucose levels and in cases of three elevated glycemic parameters (fasting, 1 h, and 2 h blood glucose at the initial results of OGTT) reduced the success rate of glycemic control to 56.5%, 49.2%, respectively, compared to the group with solely a high fasting index of blood glucose (69.6%). The pregnant women who participated in high-intensity sports activities related to a two-fold increase in success rate compared with the group engaging in light and moderate-intensity physical activity. Conclusions: The success rate of glycemic control in GDM women was highest in the group with solitary fasting hyperglycemia and lower in the contributory groups with two and three high parameters. The application of diet therapy plus physical activities among GDM pregnant women is potentially necessary to improve the effectiveness of treatment, minimize adverse pregnancy outcomes, and reduce substantially the hospitalization rate.

Intrapartum maternal glycaemic control for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

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.

Factors associated with maternal hyperglycaemia and neonatal hypoglycaemia after antenatal betamethasone administration in women with diabetes in pregnancy

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.

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

OBJECTIVE

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

DESIGN

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

SETTING

Single-centre tertiary maternity hospital in Melbourne, Australia.

POPULATION

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

METHODS

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

MAIN OUTCOME MEASURE

The proportion of eligible women who consented and were randomised.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12619001475134.

RESULTS

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

CONCLUSION

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

Betamethasone for Preterm Birth: Auckland Steroid Trial Full Results and New Insights 50 Years on

OBJECTIVES

The objective of this study was to use modern analysis and reporting methods to present the full results of the first randomized trial of antenatal corticosteroids, performed 50 years ago.

STUDY DESIGN

In this single-center trial, women at risk of preterm birth at 24 to less than 37 weeks of gestation were randomized to receive 2 doses of betamethasone or placebo, 24 hours apart. Women and their caregivers were blinded to treatment allocation. The primary outcome was respiratory distress syndrome. Secondary outcomes included measures of neonatal mortality and morbidity, mode of birth, and maternal infection.

RESULTS

Between 1969 and 1974, 1115 women (1142 pregnancies) were randomized, 560 pregnancies (601 infants) to betamethasone and 582 (617 infants) to placebo. The risk of respiratory distress syndrome was significantly reduced in the betamethasone group compared with placebo (8.8% vs 14.4%, adjusted relative risk 0.62, 95% CI 0.45-0.86, P = .004). Subgroup analyses indicated greater efficacy in male than female infants but no effect of tocolytic therapy or doubling of betamethasone dose. Fetal or neonatal death, neonatal or maternal infection, neonatal hypoglycaemia, cesarean delivery, and lactation status at discharge were not different between the groups.

CONCLUSIONS

Antenatal betamethasone administered to women at risk of preterm birth between 24 and less than 37 weeks of gestation reduces the incidence of respiratory distress syndrome, with greater effect in male than in female infants. Doubling the dose of betamethasone does not provide additional benefit.

Gestational Diabetes Mellitus and Antenatal Corticosteroid Therapy-A Narrative Review of Fetal and Neonatal Outcomes

BACKGROUND

There, we review the pathogenesis of gestational diabetes mellitus (GDM), its influence on fetal physiology, and neonatal outcomes, as well as the usage of antenatal corticosteroid therapy (ACST) in pregnancies complicated by GDM.

METHODS

MEDLINE and PubMed search was performed for the years 1990-2022, using a combination of keywords on such topics. According to the aim of the investigation, appropriate articles were identified and included in this narrative review.

RESULTS

GDM is a multifactorial disease related to unwanted pregnancy course and outcomes. Although GDM has an influence on the fetal cardiovascular and nervous system, especially in preterm neonates, the usage of ACST in pregnancy must be considered taking into account maternal and fetal characteristics.

CONCLUSIONS

GDM has no influence on neonatal outcomes after ACST introduction. The ACST usage must be personalized and considered according to its gestational age-specific effects on the developing fetus.

Low-dose antenatal betamethasone treatment achieves preterm lung maturation equivalent to that of the World Health Organization dexamethasone regimen but with reduced endocrine disruption in a sheep model of pregnancy

BACKGROUND

The intramuscular administration of antenatal steroids to women at risk of preterm delivery achieves high maternal and fetal plasma steroid concentrations, which are associated with adverse effects and may reduce treatment efficacy. We have demonstrated that antenatal steroid efficacy is independent of peak maternofetal steroid levels once exposure is maintained above a low threshold.

OBJECTIVE

This study aimed to test, using a sheep model of pregnancy, whether the low-dose antenatal steroid regimen proposed as part of the Antenatal Corticosteroids for Improving Outcomes in Preterm Newborns trial would achieve preterm lung maturation equivalent to that of the existing World Health Organization dexamethasone treatment regimen, but with reduced risk of adverse outcomes.

STUDY DESIGN

Following ethical review and approval, date-mated ewes with single fetuses received intramuscular injections of either (1) four 6-mg maternal intramuscular injections of dexamethasone phosphate every 12 hours (n=22), (2) 4 2-mg maternal intramuscular injections of betamethasone phosphate every 12 hours (n=21), or (3) 4 2-mL maternal intramuscular injections of saline every 12 hours (n=16). Of note, 48 hours after first injection, (124±1 day), lambs were delivered, ventilated for 30 minutes, and euthanized for sampling. Arterial blood gas, respiratory, hematological, and biochemical data were analyzed for between-group differences with analysis of variance according to distribution and variance, with P<.05 taken as significant.

RESULTS

After 30 minutes of ventilation, lambs from both steroid-treated groups had significant and equivalent improvements in lung function relative to saline control (P<.05). There was no significant difference in arterial blood pH, pO₂, pCO₂, lung compliance, ventilator efficiency index, or lung volume at necropsy with a static pressure of 40 cmH₂O. The messenger RNA expression of surfactant protein (Sp)a, Spb, Spc, Spd, aquaporin (Aqp)1, Aqp5, and sodium channel epithelial 1 subunit beta (Scnn1b) was equivalent between both steroid groups. Maternal and fetal plasma neutrophil, glucose, and fetal plasma C-peptide levels were significantly elevated in the dexamethasone group, relative to the betamethasone group. Fetal plasma insulin-like growth factor 1 was significantly reduced in the dexamethasone group compared with the betamethasone group (P<0.05). Fetal adrenocorticotropic hormone (r=0.53), maternal glucose value (r=-0.52), and fetal glucose values (r=-0.42) were correlated with maternal weight in the betamethasone group (P<.05), whereas fetal pCO₂ and pO₂ were not correlated. There was no significant difference between male and female lamb outcomes in any groups for any of the items evaluated.

CONCLUSION

This study reported that in preterm lambs, a low-dose treatment regimen of 8 mg betamethasone achieves lung maturation equivalent to that of a 24-mg dexamethasone-based regimen, but with smaller perturbations to the maternofetal hypothalamic-pituitary-adrenal axis. These data suggested that given steroid pharmacokinetic differences between sheep and humans, a betamethasone dose of 2 mg may remain above the minimum dose necessary for robust maturation of the preterm lung. Maternal weight-adjusted betamethasone doses might also be a key to reducing perturbations to the maternofetal hypothalamic-pituitary-adrenal axis.

Effects of antenatal corticosteroids on neonatal blood glucose fluctuation in late-preterm infants

OBJECTIVE

To evaluate the effects of antenatal corticosteroids (ACS) on blood glucose fluctuations in late-preterm neonates.

METHODS

A retrospective study was performed on 236 neonates with gestational age of 34+0 to 36+6 weeks who were admitted to the neonatology department of a tertiary general hospital in China's Zhejiang Province between April 2020 and February 2022. The neonates were divided into three groups: complete course, partial course, and control. Primary outcome was the neonatal blood glucose levels within the first 48 h of life.

RESULTS

134 (56.8%) newborns were exposed to a complete course of ACS, 56 (23.7%) had a to a partial course of ACS, and 46 (19.5%) had no exposure to ACS. The patients in the complete course group had the highest proportion of neonatal hypoglycemia (16.4% vs. 3.6% and 6.5%).The patients exposed to a complete course of dexamethasone had significantly lower blood glucose levels within 12 h of birth than the control group, although no significant differences were observed after 24 h. Differences in blood glucose levels were more significant among male infants, although blood glucose curves of the male and female infants remained close to the overall trend.

CONCLUSIONS

Blood glucose levels in late-preterm neonates may decrease after ACS administration, especially after exposure to a complete course. The effects are more pronounced in the first 12 h of life, with males being more severely affected; however, the effects on blood glucose levels were not significant 24 h after birth. This can provide a reference for future clinical studies.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes - an updated guideline from the Joint British Diabetes Society for Inpatient Care

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of glycaemia in pregnant women with diabetes on obstetric wards and delivery units, Joint British Diabetes Societies (JBDS) for Inpatient Care Group, ABCD (Diabetes Care) Ltd. The updated guideline offers two approaches - the traditional approach with tight glycaemic targets (4.0-7.0 mmol/L) and an updated pragmatic approach (5.0-8.0 mmol/L) to reduce the risk of maternal hypoglycaemia whilst maintaining safe glycaemia. This is particularly relevant for women with type 1 diabetes who are increasingly using Continuous Glucose Monitoring (CGM) and Continuous Subcutaneous Insulin Infusion (CSII) during pregnancy. All women with diabetes should have a documented delivery plan agreed during antenatal clinic appointments. Hyperglycaemia following steroid administration can be managed either by increasing basal and prandial insulin doses, typically by 50% to 80%, or by adding a variable rate of intravenous insulin infusion (VRIII). Glucose levels, either capillary blood glucose or CGM glucose levels, should be measured at least hourly from the onset of established labour, artificial rupture of membranes or admission for elective caesarean section. If intrapartum glucose levels are higher than 7.0 or 8.0 mmol/L on two consecutive occasions, VRIII is recommended. Hourly capillary blood glucose rather than CGM glucose measurements should be used to adjust VRIII. The recommended substrate fluid to be administered alongside a VRIII is 0.9% sodium chloride solution with 5% glucose and 0.15% potassium chloride (KCl) (20 mmol/L) or 0.3% KCl (40 mmol/L) at 50 ml/hr. Both the VRIII and CSII rates should be reduced by at least 50% after delivery.

Factors associated with the development of neonatal hypoglycemia after antenatal corticosteroid administration: It's all about timing

OBJECTIVE

To determine the factors associated with neonatal hypoglycemia among neonates exposed to antenatal corticosteroid (ACS).

METHODS

A retrospective study conducted during 2017-2019 at a tertiary-care center including all neonates delivered between 24 and 34 weeks of gestation after ACS administration. The primary outcome was neonatal hypoglycemia (<40 mg/dl).

RESULTS

Overall, 362 early preterm neonates, including 205 singletons and 157 twins, were exposed to ACS before delivery and constituted the study group. Of them, 275 (76.0%) were exposed to a single ACS course and 87 (24.0%) to an additional rescue ACS course. Neonatal hypoglycemia occurred in 84 (23.2%) neonates. The incidence of neonatal hypoglycemia was significantly higher in those delivered between 24 and 48 h after ACS administration compared with those delivered outside this time interval (10/25, 40.0% vs 74/337, 21.9%; P = 0.049). In multivariate analysis, after adjusting for neonatal birth weight and gestational age, delivery within 24-48 h after ACS administration was the only independent risk factor associated with neonatal hypoglycemia (adjusted odds ratio 2.41, 95% confidence interval 1.03-5.68; P = 0.044).

CONCLUSION

Neonatal hypoglycemia occurred in over one-fifth of those exposed to ACS, and was independently associated with delivery between 24 and 48 h after ACS administration.