Managing Diabetes in Pregnancy Using Cell Phone/Internet Technology

Informatics Interventions for Maternal Morbidity: Scoping Review

BACKGROUND

Women have been entering pregnancy less healthy than previous generations, placing them at increased risk for pregnancy complications. One approach to ensuring effective monitoring and treatment of at-risk women is designing technology-based interventions that prevent maternal morbidities and treat perinatal conditions.

OBJECTIVE

This scoping review evaluates what informatics interventions have been designed and tested to prevent and treat maternal morbidity.

METHODS

MEDLINE, Embase, and Cochrane Library were searched to identify relevant studies. The inclusion criteria were studies that tested a medical or clinical informatics intervention; enrolled adult women; and addressed preeclampsia, gestational diabetes mellitus (GDM), preterm birth, Centers for Disease Control and Prevention-defined severe maternal morbidity, or perinatal mental health conditions. Demographic, population, and intervention data were extracted to characterize the technologies, conditions, and populations addressed.

RESULTS

A total of 80 studies were identified that met the inclusion criteria. Many of the studies tested for multiple conditions. Of these, 73% (60/82) of the technologies were tested for either GDM or perinatal mental health conditions, and 15% (12/82) were tested for preeclampsia. For technologies, 32% (28/87) of the technologies tested were smartphone or tablet applications, 26% (23/87) were telehealth interventions, and 14% (12/87) were remote monitoring technologies. Of the many outcomes measured by the studies, almost half (69/140, 49%) were patient physical or mental health outcomes.

CONCLUSIONS

Per this scoping review, most informatics interventions address three conditions: GDM, preeclampsia, and mental health. There may be opportunities to treat other potentially lethal conditions like postpartum hemorrhage using proven technologies such as mobile apps. Ample gaps in the literature exist concerning the use of informatics technologies aimed at maternal morbidity. There may be opportunities to use informatics for lesser-targeted conditions and populations.

A scoping review of digital technologies in antenatal care: recent progress and applications of digital technologies

INTRODUCTION

Digital health technologies have vastly improved monitoring, diagnosis, and care during pregnancy. As expectant mothers increasingly engage with social media, online platforms, and mobile applications, these innovations present valuable opportunities to enhance the quality of maternal healthcare services.

OBJECTIVE

This review aims to assess the applicability, outcomes, and recent advancement of digital health modalities in antenatal care.

METHOD

We conducted a scoping review by searching four electronic databases (Scopus, Web of Science, PubMed, EBSCOhost), performing manual searches of Google Scholar, and examining the references of relevant studies. Eligible studies included original research published in English between 2010 and 2024 involving the use of digital health technologies for antenatal care, complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines.

RESULTS

One hundred twenty-six eligible articles were identified, with the majority (61.11%) conducted in high-income countries, including the United States, United Kingdom, and Australia. Digital health studies have increased over time, driven by telehealth adoption in affluent nations. Interventions predominantly focused on patient-provider consultations, remote monitoring, and health education, complementing in-person visits or as a substitute when necessary. High levels of acceptance and satisfaction were reported among users. These interventions primarily targeted general maternal care (28.57%), gestational diabetes mellitus (15.07%), and mental health (13.49%) while also addressing gestational weight management, hypertensive disorders, high-risk pregnancies and maternal education. The findings demonstrated positive outcomes in managing clinical conditions, enhancing knowledge, promoting birth preparedness, and improving antenatal care access and utilisation. Additionally, the findings revealed the cost-effectiveness of these approaches in alleviating financial burdens for patients and healthcare systems.

CONCLUSION

Digital health is emerging as a pivotal tool in maternal and child care, fostering positive outcomes and high acceptance among patients and healthcare providers. Its integration into antenatal care ensures the maintenance of standard care quality, with no adverse effects reported despite limited discussions on safety and privacy concerns. As these technologies continue to evolve, they are set to redefine antenatal care by offering more accessible, efficient, and patient-centred solutions, ultimately shaping the future of maternal healthcare delivery.

Type 1 Diabetes and Pregnancy: Challenges in Glycemic Control and Maternal-Fetal Outcomes

Managing type 1 diabetes during pregnancy presents significant challenges due to physiological and hormonal changes. These factors contribute to major changes in insulin sensitivity, complicating efforts to achieve and sustain optimal blood glucose levels. Poorly controlled glucose levels during pregnancy can result in diabetic embryopathy and elevate the risks of maternal complications such as hypertensive disorders and diabetic ketoacidosis. Fetal complications may include preterm birth, fetal demise, and admission to neonatal intensive care units. It is essential to recognize that there is no universal approach to managing glycemic control in pregnant women with T1DM and care should be individualized. Effective management requires a multidisciplinary approach involving regular monitoring, adjustments in insulin therapy, dietary modifications, and consistent prenatal care. Continuous glucose monitoring has emerged as a valuable tool for real-time glucose monitoring, facilitating tighter glycemic control. Education and support for self-management are important in addressing these challenges. Future developments in technology and personalized approaches to care show promising potential for advancing diabetes management during pregnancy. This provides a comprehensive overview of current literature on the challenges with the management of T1DM during pregnancy, focusing on its impact on maternal and neonatal outcomes and highlighting effective strategies for achieving optimal glycemic control.

The role of technology in the care of diabetes mellitus in pregnancy: an expert review

Diabetes mellitus is one of the most commonly encountered pregnancy complications and is associated with multiple adverse perinatal outcomes. Technology has progressed to address the unique challenges patients face in managing diabetes mellitus in pregnancy. Technology has bolstered diabetes mellitus education with smartphone applications focused on nutrition counseling and carbohydrate intake advice. Continuous glucose monitors and insulin infusion systems have shown benefit by simplifying glycemic monitoring and insulin administration. Improvements in glycemic control and perinatal outcomes have been seen with continuous glucose monitor use when compared with intermittent blood glucose monitoring, and more pregnant people are using insulin pumps instead of multiple daily insulin injections. Hybrid closed-loop systems are emerging and are able to integrate continuous glucose monitoring and insulin pump technologies while maximizing automated features in the nonpregnant population, but these have not been endorsed for use in pregnancy yet. Applying telehealth practices has been associated with high patient satisfaction among those with diabetes mellitus in pregnancy, and leveraging remote patient monitoring through telehealth platforms and short-range wireless technologies can reduce the burden of patient visits. As technology becomes more integrated into routine management of diabetes mellitus in pregnancy, practitioners should emphasize individualized counseling and device selection to ensure patient autonomy and safety.

Patient-reported Benefits and Limitations of Mobile Health Technologies for Diabetes in Pregnancy: A Scoping Review

OBJECTIVES

For women with pre-existing and gestational diabetes, pregnancy involves specialized and intensive medical care to optimize maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. COVID-19-induced barriers to face-to-face care have identified the need for high-quality, patient-centred virtual health-care modalities, such as mobile health (mHealth) technologies. Our aim in this review was to identify the patient-reported benefits and limitations of mHealth technologies among women with diabetes in pregnancy. We also aimed to determine how the women's experiences aligned with the best practice standards for patient-centred communication.

METHODS

The framework presented by Arksey and O'Malley for conducting scoping reviews, with refinements by Levac et al, was used to guide this review. Relevant studies were identified through comprehensive database searches of MEDLINE, Embase, Emcare and PsycINFO. Thomas and Harden's methods for the thematic synthesis of qualitative research in systematic reviews guided the synthesis of patient-reported benefits and limitations of mHealth technology.

RESULTS

Overall, 19 studies describing the use of 16 unique mHealth technologies among 742 women were included in the final review. Patient-reported benefits of mHealth included convenience, support of psychosocial well-being and facilitation of diabetes self-management. Patient-reported limitations included lack of important technological features, perceived burdensome aspects of mHealth and lack of trust in virtual health care.

CONCLUSIONS

Women with diabetes report some benefits from mHealth use during pregnancy. Codesigning future technologies with end users may help address the perceived limitations and effectiveness of mHealth technologies.

Community-based non-pharmacological interventions for pregnant women with gestational diabetes mellitus: a systematic review

BACKGROUND

Non-pharmacological interventions are the first line of Gestational diabetes mellitus (GDM) management. Community-based interventions are cheaper, more accessible, with higher patient satisfaction.

OBJECTIVES

To systematically review community-based non-pharmacological interventions and evaluate their effectiveness for GDM.

SEARCH STRATEGY

Twelve bibliographic databases and reference list of related studies from inception until January 2022.

SELECTION CRITERIA

All primary studies of community-based non-pharmacological interventions for GDM reported in English which investigated any behavioural or clinical outcome(s).

DATA COLLECTION AND ANALYSIS

Data were extracted using modified Cochrane's data extraction template. Studies were evaluated using Cochrane Collaboration's risk of bias tool. Narrative synthesis was used to summarise findings. This study is registered with PROSPERO (CRD42021257634).

MAIN RESULTS

Twenty-seven studies involving 6,242 pregnant women with GDM investigated self-management programmes, medical nutrition/diet therapy, exercise/physical activity, combined diet and exercise, calcium plus vitamin D supplementation, and continuous glucose monitoring. Self-management programmes were more effective than routine care in improving self-efficacy, two-hour postprandial blood glucose, and lifestyle behaviours but were as effective as routine care in improving infant birth weight. Self-management programmes were superior to or as effective as usual care in improving fasting blood glucose, blood glucose control, glycated haemoglobin, macrosomia, and preterm delivery. Medical nutrition/diet therapy was more effective than usual care in improving postprandial blood glucose levels. Postprandial blood glucose levels were better improved by regular supervised exercise plus daily brisk walks or a daily walking intervention than routine obstetric care or no treatment. The effects of exercise/physical activity programmes were mostly inconsistent for other outcomes. Diet and exercise were superior to diet alone in reducing maternal weight gain although there were similar outcomes for other pregnancy and foetal outcomes. Limited or conflicting evidence was found for other outcomes and interventions including calcium and vitamin D supplementation and continuous glucose monitoring intervention.

CONCLUSIONS

Community-based non-pharmacological interventions are more effective than placebo; and are more or as effective as usual care. Self-management programmes and medical nutrition/diet therapy had the most promising GDM outcomes.

FUNDING

There was no funding for this study. The study design, data collection, data analysis and interpretation, and writing of this manuscript were not influenced externally by any funder.

Telehealth for the Management of Diabetes in Pregnancy

PURPOSE OF REVIEW

Telehealth initiatives are becoming ubiquitous in clinical practice and can be a useful tool in the management of diabetes in pregnancy. The purpose of this review is to summarize new techniques in telemedicine delivery and offer details on how to leverage telehealth in delivering care to pregnant women with diabetes.

RECENT FINDINGS

Using mobile phone technology to collect glucose values in women with gestational diabetes has been found to be beneficial by increasing the amount of glucose data available for interpretation. Remote patient monitoring in non-pregnant people with type 2 diabetes has shown a modest improvement in glucose control. In pregnant women with diabetes, the use of remote patient monitoring does not appear to improve outcomes but can decrease in-office visits and lower healthcare costs. However, telehealth may not be the only solution to helping patients with diabetes in pregnancy who have difficulty engaging in their care. Telehealth affords improvements in convenience, efficiency, and frequency of communication with healthcare professionals, and the amount of data available to patients and providers alike, yielding the potential for better outcomes when telehealth modalities are adopted.

Quality of patient-reported outcome reporting in trials of diabetes in pregnancy: A systematic review

AIMS

Patient-reported outcomes (PROs) are reports of the patient's health status that come directly from the patient without interpretation by the clinician or anyone else. They are increasingly used in randomised controlled trials (RCTs). In this systematic review we identified RCTs conducted in women with diabetes in pregnancy which included PROs in their primary or secondary outcomes. We then evaluated the quality of PRO reporting against an internationally accepted reporting framework (Consolidated Standards of Reporting Trials (CONSORT-PRO) guidelines).

METHODS

We searched online databases for studies published 2013-2021 using a combination of keywords. Two authors reviewed all abstracts independently. Data on study characteristics and the quality of PRO reporting were extracted from relevant studies. We conducted a multiple regression analysis to identify factors associated with high quality reporting.

RESULTS

We identified 7122 citations. Thirty-five articles were included for review. Only 17% of RCTs included a PRO as a primary or secondary outcome. Out of a maximum score of 100 the median score was 46, indicating sub-optimal reporting. A multiple regression analysis did not reveal any factors associated with high quality reporting.

CONCLUSIONS

Researchers should be mindful of the importance of PRO inclusion and reporting and include reliable PROs in trials.

Barriers and Facilitators of Using eHealth to Support Gestational Diabetes Mellitus Self-Management (GDM): A Systematic Literature Review of Perceptions of Healthcare Professionals and Women with GDM (Preprint)

Background

Gestational diabetes mellitus (GDM) is one of the most common medical complications during pregnancy. eHealth technologies are proving to be successful in supporting the self-management of medical conditions. Digital technologies have the potential to improve GDM self-management.

Objective

The primary objective of this systematic literature review was to identify the views of health professionals (HPs) and women with GDM regarding the use of eHealth for GDM self-management. The secondary objective was to investigate the usability and user satisfaction levels when using these technologies.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach, the search included primary papers in English on the evaluation of technology to support self-management of GDM from January 2008 to September 2021 using MEDLINE, CINAHL, Embase, ACM, and IEEE databases. The lists of references from previous systematic literature reviews, which were related to technology and GDM, were also examined for primary studies. Papers with qualitative, quantitative, and mixed methodologies were included and evaluated. The selected papers were assessed for quality using the Cochrane Collaboration tool, National Institute for Health and Care Excellence clinical guidelines, Critical Appraisal Skills Programme Qualitative Checklist, and McGill University Mixed Methods Appraisal Tool. NVivo (QSR International) was used to extract qualitative data, which were subjected to thematic analysis. Narrative synthesis was used to analyze the quantitative data.

Results

A total of 26 papers were included in the review. Of these, 19% (5/26) of studies used quantitative research methodologies, 19% (5/26) used qualitative methods, and 62% (16/26) used mixed methods. In all, 4 themes were identified from the qualitative data: the benefits of using technology, engagement with people via technology, the usability of technology, and discouragement factors for the use of technology. The thematic analysis revealed a vast scope of challenges and facilitators in the use of GDM self-management systems. The challenges included usability aspects of the system, technical problems, data privacy, lack of emotional support, the accuracy of reported data, and adoption of the system by HPs. Convenience, improved GDM self-management, peer support, increased motivation, increased independence, and consistent monitoring were facilitators to use these technologies. Quantitative data showed that there is potential for improving the usability of the GDM self-management systems. It also showed that convenience, usefulness, increasing motivation for GDM self-management, helping with GDM self-management, and being monitored by HPs were facilitators to use the GDM self-management systems.

Conclusions

This novel systematic literature review shows that HPs and women with GDM encountered some challenges in using GDM self-management systems. The usability of GDM systems was the primary challenge derived from qualitative and quantitative results, with convenience, consistent monitoring, and optimization of GDM self-management emerging as important facilitators.

Digital health interventions for gestational diabetes mellitus: A systematic review and meta-analysis of randomised controlled trials

Good blood glucose control is important to reduce the risk of adverse effects on mothers and their offspring in women with gestational diabetes (GDM). This review examined the impact of using digital health interventions on reported glycaemic control among pregnant women with GDM and its impact on maternal and foetal outcomes. Seven databases were searched from database inception to October 31st, 2021 for randomised controlled trials that examined digital health interventions to provide services remotely for women with GDM. Two authors independently screened and assessed the studies for eligibility for inclusion. Risk of bias was independently assessed using the Cochrane Collaboration's tool. Studies were pooled using random effects model and presented as risk ratio or mean difference with 95% confidence intervals. Quality of evidence was assessed using GRADE framework. Twenty-eight randomised controlled trials that examined digital health interventions in 3,228 pregnant women with GDM were included. Moderate certainty of evidence showed that digital health interventions improved glycaemic control among pregnant women, with lower fasting plasma glucose (mean difference -0.33 mmol/L; 95% CI: -0.59 to -0.07), 2-hour post-prandial glucose (-0.49 mmol/L; -0.83 to -0.15) and HbA1c (-0.36%; -0.65 to -0.07). Among those randomised to digital health interventions, there was a lower need for caesarean delivery (Relative risk: 0.81; 0.69 to 0.95; high certainty) and foetal macrosomia (0.67; 0.48 to 0.95; high certainty). Other maternal and foetal outcomes were not significantly different between both groups. Moderate to high certainty evidence support the use of digital health interventions, as these appear to improve glycaemic control and reduce the need for caesarean delivery. However, more robust evidence is needed before it can be offered as a choice to supplement or replace clinic follow up. Systematic review registration: PROSPERO: CRD42016043009.

Type 1 Diabetes in Pregnancy: A Review of Complications and Management

BACKGROUND

Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent's declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes.

OBJECTIVES

This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care.

METHODS

A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised.

RESULTS

One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised.

CONCLUSION

This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.

Effectiveness of a Nurse-Led Web-Based Health Management in Preventing Women With Gestational Diabetes From Developing Metabolic Syndrome

BACKGROUND

Women with gestational diabetes mellitus (GDM) are more likely to develop metabolic syndrome (MS). However, the effectiveness of web-based health management in preventing women at high risk of GDM from developing MS has rarely been studied.

PURPOSE

The aim of this study was to evaluate the longitudinal effects of nurse-led web-based health management on maternal anthropometric, metabolic measures, and neonatal outcomes.

METHODS

A randomized controlled trial was conducted from February 2017 to February 2018, in accordance with the Consolidated Standards of Reporting Trials guidelines. Data were collected from 112 pregnant women at high risk of GDM who had been screened from 984 potential participants in northern Taiwan. Participants were randomly assigned to the intervention group (n = 56) or the control group (n = 56). The intervention group received a 6-month nurse-led, web-based health management program as well as consultations conducted via the LINE mobile app. Anthropometric and metabolic measures were assessed at baseline (Time 0, prior to 28 weeks of gestation), Time 1 (36-40 weeks of gestation), and Time 2 (6-12 weeks of postpartum). Maternal and neonatal outcomes were assessed at delivery. Clinical trial was registered.

RESULTS

Analysis using the general estimating equation models found that anthropometric and metabolic measures were significantly better in the intervention group than the control group and varied with time. At Time 1, the levels of diastolic pressure (β = -4.981, p = .025) and triglyceride (TG; β = -33.69, p = .020) were significantly lower in the intervention group than the control group, and at Time 2, the incidence of MS in the intervention group was lower than that in the control group (χ2 = 6.022, p = .014). The number of newborns with low birth weight in the intervention group was lower than that in the control group (χ2 = 6.729, p = .012).

CONCLUSION/IMPLICATIONS FOR PRACTICE

This nurse-led, web-based health management was shown to be effective in improving MS outcomes and may play an important role and show feasible clinical value in changing the current pregnancy care model.

A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes

BACKGROUND

Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence.

OBJECTIVES

To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM.

SEARCH STRATEGY

CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020.

SELECTION CRITERIA

Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group.

MAIN RESULTS

Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1).

CONCLUSIONS

Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes.

REGISTRATION

The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549).

TWEETABLE ABSTRACT

Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.

A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study

Objective

To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM).

Design

A consensus developmental study.

Setting

International.

Population

Two hundred and five stakeholders completed the first round.

Methods

The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS.

Main outcome measures

All outcomes were extracted from the literature.

Results

We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death.

Conclusions

This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM.

165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.

Challenge of diabetes mellitus and researchers’ contributions to its control

The aim of this review study was to assess the past significant events on diabetes mellitus, transformations that took place over the years in the medical records of treatment, countries involved, and the researchers who brought about the revolutions. This study used the content analysis to report the existence of diabetes mellitus and the treatments provided by researchers to control it. The focus was mainly on three main types of diabetes (type 1, type 2, and type 3 diabetes). Ethical consideration has also helped to boost diabetic studies globally. The research has a history path from pharmaceuticals of organic-based drugs to metal-based drugs with their nanoparticles in addition to the impacts of nanomedicine, biosensors, and telemedicine. Ongoing and future studies in alternative medicine such as vanadium nanoparticles (metal nanoparticles) are promising.

Self-management education among women with pre-existing diabetes in pregnancy: A scoping review

BACKGROUND

Education is a cornerstone of self-management for adults with diabetes. Self-management is particularly important during pregnancy for women with type 1 and type 2 diabetes, as perinatal outcomes are affected by maternal glycemic control. To our knowledge, literature describing the provision of diabetes education and support during pregnancy for women with type 1 and type 2 diabetes has not been synthesized, nor examined within its context as a complex intervention.

OBJECTIVES AND DESIGN

This scoping review aims to synthesize the evidence regarding prenatal diabetes education and support for women with type 1 and type 2 diabetes and to apply the Medical Research Council framework for complex interventions where appropriate.

DATA SOURCES AND METHODS

We searched EMBASE, CINAHL, and MEDLINE from inception to February 2019 for primary studies focused on prenatal diabetes education among women with type 1 and type 2 diabetes. Two independent reviewers screened eligible studies against inclusion criteria. A narrative synthesis of the included studies was conducted.

RESULTS

Of 511 identified citations, 30 studies were included in the final review. Approximately 44% of the pooled sample were women with type 1 diabetes, 46% had gestational diabetes mellitus, and 10% had type 2 diabetes. Education focused on self-monitoring of blood glucose, attaining glycemic targets, and following a healthy diet. Many studies included educational elements that went beyond traditional didactic teaching and promoted self-management skills and self-management support. The majority of education was delivered via one-on-one outpatient appointments every one to three weeks. About half of the reviewed studies used a multidisciplinary team approach, with most including a combination of physicians, nurses, dietitians, and midwives. Application of the Medical Research Council framework revealed that most studies were limited in methods (i.e., randomization) and few examined process evaluation or intervention cost-effectiveness.

CONCLUSION

We identified a lack of studies centred on educational interventions for women with type 2 diabetes in pregnancy. As pregnancy for women with type 2 diabetes involves significant changes, including the transition from oral hypoglycemics to insulin therapy, often without exposure to diabetes-specific preconception care and counselling, future research may focus on optimizing preconception and prenatal education and support for this high-risk group. This is particularly relevant as the prevalence of type 2 diabetes is increasing worldwide. Future research ought to also design, implement and evaluate interventions in accordance with the Medical Research Council framework for complex interventions.

Comparison Between In-Person and Audio-Only Virtual Prenatal Visits and Perinatal Outcomes

IMPORTANCE

Ensuring access to prenatal care services in the US is challenging, and implementation of telehealth options was limited before the COVID-19 pandemic, especially in vulnerable populations, given the regulatory requirements for video visit technology.

OBJECTIVE

To explore the association of audio-only virtual prenatal care with perinatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study compared perinatal outcomes of women who delivered between May 1 and October 31, 2019 (n = 6559), and received in-person prenatal visits only with those who delivered between May 1 and October 31, 2020 (n = 6048), when audio-only virtual visits were integrated into prenatal care during the COVID-19 pandemic, as feasible based on pregnancy complications. Parkland Health and Hospital System in Dallas, Texas, provides care to the vulnerable obstetric population of the county via a high-volume prenatal clinic system and public maternity hospital. All deliveries of infants weighing more than 500 g, whether live or stillborn, were included.

EXPOSURES

Prenatal care incorporating audio-only prenatal care visits.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of placental abruption, stillbirth, neonatal intensive care unit admission in a full-term (≥37 weeks) infant, and umbilical cord blood pH less than 7.0. Visit data, maternal characteristics, and other perinatal outcomes were also examined.

RESULTS

The mean (SD) age of the 6559 women who delivered in 2019 was 27.8 (6.4) years, and the age of the 6048 women who delivered in 2020 was 27.7 (6.5) years (P = .38). Of women delivering in 2020, 1090 (18.0%) were non-Hispanic Black compared with 1067 (16.3%) in 2019 (P = .04). In the 2020 cohort, 4067 women (67.2%) attended at least 1 and 1216 women (20.1%) attended at least 3 audio-only virtual prenatal visits. Women who delivered in 2020 attended a greater mean (SD) number of prenatal visits compared with women who delivered in 2019 (9.8 [3.4] vs 9.4 [3.8] visits; P < .001). In the 2020 cohort, 173 women (2.9%) experienced the composite outcome, which was not significantly different than the 195 women (3.0%) in 2019 (P = .71). In addition, the rate of the composite outcome did not differ substantially when examined according to the number of audio-only virtual visits attended.

CONCLUSIONS AND RELEVANCE

Implementation of audio-only virtual prenatal visits was not associated with changes in perinatal outcomes and increased prenatal visit attendance in a vulnerable population during the COVID-19 pandemic when used in a risk-appropriate model.

Developing a core outcome set for the treatment of pregnant women with pregestational diabetes-a study protocol

BACKGROUND

Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes including increased rates of caesarean section birth, macrosomia, congenital malformation, prematurity, admission to the neonatal intensive care unit and stillbirth. As a result, there has been an increase in interventions to improve outcomes in both mother and infant. To date, meaningful comparisons between these studies are limited due to heterogeneity in outcome selection and reporting. The aim of this study is to develop a core outcome set (COS) for randomised controlled trials evaluating the effectiveness of interventions for the treatment of pregnant women with PGDM.

METHODS

The study consists of three steps. The first step is a systematic review of the literature to assess outcomes reported in randomised controlled trials assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. The second step is a three round, online Delphi survey to prioritise these outcomes. In this step, stakeholders (including women with PGDM, healthcare workers, researchers and policymakers) will be asked to rank the importance of outcomes for inclusion in the COS using a 9-point Likert type scale. Outcomes that meet the inclusion criteria after completion of the Delphi surveys will be brought to the consensus meeting. The consensus meeting will be the third and final step, where the COS will be finalised. The consensus meeting will include members from each stakeholder group.

DISCUSSION

This paper describes the process used to develop a COS for the reporting of studies evaluating the effectiveness of interventions in pregnant women with PGDM. The COS will enable greater comparison between and information synthesis across RCTs in the treatment of PGDM. In addition, this COS will also help improve trial reporting and minimise research waste by prioritising the collection and reporting of outcomes that matter to all relevant stakeholder groups.

TRIAL REGISTRATION

This COS has been registered with the Core Outcome Measures in Effectiveness Trials (COMET) initiative ( http://www.comet-initiative.org/studies/details/1425 ) on the 4th of November 2019. The systematic review component of this study has also been registered with the International Prospective Register of Systematic Reviews (PROSPERO) ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020173549 ).

Practice Modification for Pandemics: A Model for Surge Planning in Obstetrics

This review highlights proposed pandemic-adjusted modifications in obstetric care, with discussion of risks and benefits based on available evidence. We suggest best practices for balancing community-mitigation efforts with appropriate care of obstetric patients.

Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes

BACKGROUND

There are a number of ways of monitoring blood glucose in women with diabetes during pregnancy, with self-monitoring of blood glucose (SMBG) recommended as a key component of the management plan. No existing systematic reviews consider the benefits/effectiveness of different techniques of blood glucose monitoring on maternal and infant outcomes among pregnant women with pre-existing diabetes. The effectiveness of the various monitoring techniques is unclear. This review is an update of a review that was first published in 2014 and subsequently updated in 2017.

OBJECTIVES

To compare techniques of blood glucose monitoring and their impact on maternal and infant outcomes among pregnant women with pre-existing diabetes.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM), automated telemedicine monitoring or clinic monitoring among pregnant women with pre-existing diabetes mellitus (type 1 or type 2). Trials investigating timing and frequency of monitoring were also eligible for inclusion. RCTs using a cluster-randomised design were eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This review update includes a total of 12 trials (863) women (792 women with type 1 diabetes and 152 women with type 2 diabetes). The trials took place in Europe, the USA and Canada. Three of the 12 included studies are at low risk of bias, eight studies are at moderate risk of bias, and one study is at high risk of bias. Four trials reported that they were provided with the continuous glucose monitors free of charge or at a reduced cost by the manufacturer.Continuous glucose monitoring (CGM) versus intermittent glucose monitoring, (four studies, 609 women)CGM may reduce hypertensive disorders of pregnancy (pre-eclampsia and pregnancy-induced hypertension) (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.85; 2 studies, 384 women; low-quality evidence), although it should be noted that only two of the four relevant studies reported data for this composite outcome. Conversely, this did not translate into a clear reduction for pre-eclampsia (RR 0.65, 95% CI 0.39 to 1.08; 4 studies, 609 women, moderate-quality evidence). There was also no clear reduction in caesarean section (average RR 0.94, 95% CI 0.75 to 1.18; 3 studies, 427 women; I2 = 41%; moderate-quality evidence) or large-for-gestational age (average RR 0.84, 95% CI 0.57 to 1.26; 3 studies, 421 women; I2 = 70%; low-quality evidence) with CGM. There was not enough evidence to assess perinatal mortality (RR 0.82, 95% CI 0.05 to 12.61, 71 infants, 1 study; low-quality evidence), or mortality or morbidity composite (RR 0.80, 95% CI 0.61 to 1.06; 1 study, 200 women) as the evidence was based on single studies of low quality. CGM appears to reduce neonatal hypoglycaemia (RR 0.66, 95% CI 0.48 to 0.93; 3 studies, 428 infants). Neurosensory disability was not reported.Other methods of glucose monitoringFor the following five comparisons, self-monitoring versus a different type of self-monitoring (two studies, 43 women); self-monitoring at home versus hospitalisation (one study, 100 women), pre-prandial versus post-prandial glucose monitoring (one study, 61 women), automated telemedicine monitoring versus conventional system (three studies, 84 women), and constant CGM versus intermittent CGM (one study, 25 women), it is uncertain whether any of the interventions has any impact on any of our GRADE outcomes (hypertensive disorders of pregnancy, caesarean section, large-for-gestational age) because the quality of the evidence was found to be very low. This was due to evidence largely being derived from single trials, with design limitations and limitations with imprecision (wide CIs, small sample sizes, and few events). There was not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Other important outcomes, such as neurosensory disability, were not reported in any of these comparisons.

AUTHORS' CONCLUSIONS

Two new studies (406 women) have been incorporated to one of the comparisons for this update. Although the evidence suggests that CGM in comparison to intermittent glucose monitoring may reduce hypertensive disorders of pregnancy, this did not translate into a clear reduction for pre-eclampsia, and so this result should be viewed with caution. No differences were observed for other primary outcomes for this comparison. The evidence base for the effectiveness of other monitoring techniques analysed in the other five comparisons is weak and based on mainly single studies with very low-quality evidence. Additional evidence from large well-designed randomised trials is required to inform choices of other glucose monitoring techniques and to confirm the effectiveness of CGM.

Recent advances in the antepartum management of diabetes

Gestational and pre-gestational diabetes are frequent problems encountered in obstetrical practice and their complications may influence both the mother (such as hypertension, pre-eclampsia, increased caesarean rates) and the foetus (such as macrosomia, shoulder dystocia, respiratory distress, hypoglycaemia, or childhood obesity and diabetes). Given the important implications for mothers and their offspring, screening and appropriate management of diabetes during pregnancy are essential. This is a review of articles published between 2015 and 2018 on Medline via Ovid that focus on advances in the management of diabetes in pregnancy. Recent data have concentrated predominantly on optimising glycaemic control, which is key for minimising the burden of maternal and foetal complications. Lifestyle changes, notably physical exercise and diet adjustments, appear to have beneficial effects. However, data are inconclusive with respect to which diet and form of exercise provide optimal benefits. Oral glycaemic agents-in particular, metformin-are gaining acceptance as more data indicating their long-term safety for the foetus and newborn emerge. Recent reviews present inconclusive data on the efficacy and safety of insulin analogues. New technologies such as continuous insulin pumps for type 1 diabetes and telemedicine-guided management of diabetes are significantly appreciated by patients and represent promising clinical tools. There are few new data addressing the areas of antenatal foetal surveillance, the timing and need for induction of delivery, and the indications for planned caesarean section birth.

Assessment of Psychological Dimensions in Telemedicine Care for Gestational Diabetes Mellitus: A Systematic Review of Qualitative and Quantitative Studies

Background and Objective: Gestational Diabetes Mellitus (GDM) is a complex and wide spread problem and is considered one of the most frequent chronic metabolic conditions during pregnancy. According to a recent consensus conference held in Italy, new technologies can play a role in the so-called process of fertilization of the individual's ecosystem engagement, representing support for systemic collaboration among the main actors. The current systematic review aimed at providing an update of the literature about telemedicine for GDM, considering the role of psychological dimensions such as empowerment/self-efficacy, engagement and satisfaction.

Methods: The review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. The data sources were PubMed, ScienceDirect, Cochrane, and Scopus databases.

Results: Thirteen articles were identified as eligible and relevant for the final qualitative synthesis, but none was specific for the topic of engagement. The quality or research bias of the studies presents methodological limits. Most studies had clinical outcomes as a primary object. Concerning empowerment and self-efficacy, there were only preliminary findings reporting any improvements derived from using telemedicine approaches. Conversely, there were more consistent and positive results concerning the satisfaction of patients and clinicians.

Conclusions: These results are not sufficient to state a conclusive evaluation of positive effects of telemedicine use for GDM care. A more in-depth investigation of engagement and empowerment dimensions is necessary, as some benefits for the management of chronic conditions were already detected. Further investigations will also be necessary concerning the acceptability and feasibility of telemedicine systems by clinicians.

Assessment of Health Information Technology Interventions in Evidence-Based Medicine: A Systematic Review by Adopting a Methodological Evaluation Framework

BACKGROUND

The application of Health Information Technologies (HITs) can be an effective way to advance medical research and health services provision. The two-fold objective of this work is to: (i) identify and review state-of-the-art HITs that facilitate the aims of evidence-based medicine and (ii) propose a methodology for HIT assessment.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Furthermore, we consolidated existing knowledge in the field and proposed a Synthesis Framework for the Assessment of Health Information Technology (SF/HIT) in order to evaluate the joint use of Randomized Controlled Trials (RCTs) along with HITs in the field of evidence-based medicine.

RESULTS

55 articles met the inclusion criteria and refer to 51 (RCTs) published between 2008 and 2016. Significant improvements in healthcare through the use of HITs were observed in the findings of 31 out of 51 trials-60.8%. We also confirmed that RCTs are valuable tools for assessing the effectiveness, acceptability, safety, privacy, appropriateness, satisfaction, performance, usefulness and adherence.

CONCLUSIONS

To improve health service delivery, RCTs apply and exhibit formalization by providing measurable outputs. Towards this direction, we propose the SF/HIT as a framework which may help researchers to carry out appropriate evaluations and extend their studies.

Different methods and settings for glucose monitoring for gestational diabetes during pregnancy

BACKGROUND

Incidence of gestational diabetes mellitus (GDM) is increasing worldwide. Blood glucose monitoring plays a crucial part in maintaining glycaemic control in women with GDM and is generally recommended by healthcare professionals. There are several different methods for monitoring blood glucose which can be carried out in different settings (e.g. at home versus in hospital).

OBJECTIVES

The objective of this review is to compare the effects of different methods and settings for glucose monitoring for women with GDM on maternal and fetal, neonatal, child and adult outcomes, and use and costs of health care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-randomised controlled trials (qRCTs) comparing different methods (such as timings and frequencies) or settings, or both, for blood glucose monitoring for women with GDM.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, and extracted data. Data were checked for accuracy.We assessed the quality of the evidence for the main comparisons using GRADE, for:- primary outcomes for mothers: that is, hypertensive disorders of pregnancy; caesarean section; type 2 diabetes; and- primary outcomes for children: that is, large-for-gestational age; perinatal mortality; death or serious morbidity composite; childhood/adulthood neurosensory disability;- secondary outcomes for mothers: that is, induction of labour; perineal trauma; postnatal depression; postnatal weight retention or return to pre-pregnancy weight; and- secondary outcomes for children: that is, neonatal hypoglycaemia; childhood/adulthood adiposity; childhood/adulthood type 2 diabetes.

MAIN RESULTS

We included 11 RCTs (10 RCTs; one qRCT) that randomised 1272 women with GDM in upper-middle or high-income countries; we considered these to be at a moderate to high risk of bias. We assessed the RCTs under five comparisons. For outcomes assessed using GRADE, we downgraded for study design limitations, imprecision and inconsistency. Three trials received some support from commercial partners who provided glucose meters or financial support, or both. Main comparisons Telemedicine versus standard care for glucose monitoring (five RCTs): we observed no clear differences between the telemedicine and standard care groups for the mother, for:- pre-eclampsia or pregnancy-induced hypertension (risk ratio (RR) 1.49, 95% confidence interval (CI) 0.69 to 3.20; 275 participants; four RCTs; very low quality evidence);- caesarean section (average RR 1.05, 95% CI 0.72 to 1.53; 478 participants; 5 RCTs; very low quality evidence); and- induction of labour (RR 1.06, 95% CI 0.63 to 1.77; 47 participants; 1 RCT; very low quality evidence);or for the child, for:- large-for-gestational age (RR 1.41, 95% CI 0.76 to 2.64; 228 participants; 3 RCTs; very low quality evidence);- death or serious morbidity composite (RR 1.06, 95% CI 0.68 to 1.66; 57 participants; 1 RCT; very low quality evidence); and- neonatal hypoglycaemia (RR 1.14, 95% CI 0.48 to 2.72; 198 participants; 3 RCTs; very low quality evidence).There were no perinatal deaths in two RCTs (131 participants; very low quality evidence). Self-monitoring versus periodic glucose monitoring (two RCTs): we observed no clear differences between the self-monitoring and periodic glucose monitoring groups for the mother, for:- pre-eclampsia (RR 0.17, 95% CI 0.01 to 3.49; 58 participants; 1 RCT; very low quality evidence); and- caesarean section (average RR 1.18, 95% CI 0.61 to 2.27; 400 participants; 2 RCTs; low quality evidence);or for the child, for:- perinatal mortality (RR 1.54, 95% CI 0.21 to 11.24; 400 participants; 2 RCTs; very low quality evidence);- large-for-gestational age (RR 0.82, 95% CI 0.50 to 1.37; 400 participants; 2 RCTs; low quality evidence); and- neonatal hypoglycaemia (RR 0.64, 95% CI 0.39 to 1.06; 391 participants; 2 RCTs; low quality evidence). Continuous glucose monitoring system (CGMS) versus self-monitoring of glucose (two RCTs): we observed no clear differences between the CGMS and self-monitoring groups for the mother, for:- caesarean section (RR 0.91, 95% CI 0.68 to 1.20; 179 participants; 2 RCTs; very low quality evidence);or for the child, for:- large-for-gestational age (RR 0.67, 95% CI 0.43 to 1.05; 106 participants; 1 RCT; very low quality evidence) and- neonatal hypoglycaemia (RR 0.79, 95% CI 0.35 to 1.78; 179 participants; 2 RCTs; very low quality evidence).There were no perinatal deaths in the two RCTs (179 participants; very low quality evidence). Other comparisons Modem versus telephone transmission for glucose monitoring (one RCT): none of the review's primary outcomes were reported in this trial Postprandial versus preprandial glucose monitoring (one RCT): we observed no clear differences between the postprandial and preprandial glucose monitoring groups for the mother, for:- pre-eclampsia (RR 1.00, 95% CI 0.15 to 6.68; 66 participants; 1 RCT);- caesarean section (RR 0.62, 95% CI 0.29 to 1.29; 66 participants; 1 RCT); and- perineal trauma (RR 0.38, 95% CI 0.11 to 1.29; 66 participants; 1 RCT);or for the child, for:- neonatal hypoglycaemia (RR 0.14, 95% CI 0.02 to 1.10; 66 participants; 1 RCT).There were fewer large-for-gestational-age infants born to mothers in the postprandial compared with the preprandial glucose monitoring group (RR 0.29, 95% CI 0.11 to 0.78; 66 participants; 1 RCT).

AUTHORS' CONCLUSIONS

Evidence from 11 RCTs assessing different methods or settings for glucose monitoring for GDM suggests no clear differences for the primary outcomes or other secondary outcomes assessed in this review.However, current evidence is limited by the small number of RCTs for the comparisons assessed, small sample sizes, and the variable methodological quality of the RCTs. More evidence is needed to assess the effects of different methods and settings for glucose monitoring for GDM on outcomes for mothers and their children, including use and costs of health care. Future RCTs may consider collecting and reporting on the standard outcomes suggested in this review.

Efficacy of Internet-Based Self-Monitoring Interventions on Maternal and Neonatal Outcomes in Perinatal Diabetic Women: A Systematic Review and Meta-Analysis

Background

Self-monitoring using the Internet offers new opportunities to engage perinatal diabetic women in self-management to reduce maternal and neonatal complications.

Objective

This review aims to synthesize the best available evidence to evaluate the efficacy of Internet-based self-monitoring interventions in improving maternal and neonatal outcomes among perinatal diabetic women.

Methods

The review was conducted using Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsyINFO, Scopus, and ProQuest Dissertations and Theses to search for English-language research studies without any year limitation. A risk of bias table was used to assess methodological quality. Meta-analysis was performed with RevMan software. Cochran Q and I² tests were used to assess heterogeneity. The overall effect was assessed using z tests at P<.05. Of the 438 studies identified through electronic searches and reference lists, nine experimental studies from 10 publications were selected.

Results

Half of the selected studies showed low risk of bias and comprised 852 perinatal diabetic women in six countries. The meta-analysis revealed that Internet-based self-monitoring interventions significantly decreased the level of maternal glycated hemoglobin A1c (z=2.23, P=.03) compared to usual care among perinatal diabetic women at postintervention. Moreover, Internet-based self-monitoring interventions significantly decreased the cesarean delivery rate (z=2.23, P=.03) compared to usual care among the mixed group at postintervention.

Conclusions

This review shows neonatal or other maternal outcomes are similar between Internet-based self-monitoring interventions and usual diabetes care among perinatal diabetic women. The long-term effects of the intervention must be confirmed in future studies using randomized controlled trials and follow-up data.