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Søholm JC, Nørgaard SK, Nørgaard K, Clausen TD, Damm P, Mathiesen ER, Ringholm L. Mean Glucose and Gestational Weight Gain as Predictors of Large-for-Gestational-Age Infants in Pregnant Women with Type 1 Diabetes Using Continuous Glucose Monitoring. Diabetes Technol Ther 2024. [PMID: 38417013 DOI: 10.1089/dia.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
Aims/hypothesis: To compare glycemic metrics during pregnancy between women with type 1 diabetes (T1D) delivering large-for-gestational-age (LGA) and appropriate-for-gestational-age (AGA) infants, and to identify predictors of LGA infants. Materials and Methods: A cohort study including 111 women with T1D using intermittently scanned continuous glucose monitoring from conception until delivery. Average sensor-derived metrics: mean glucose, time in range in pregnancy (TIRp), time above range in pregnancy, time below range in pregnancy, and coefficient of variation throughout pregnancy and in pregnancy intervals of 0-10, 11-21, 22-33, and 34-37 weeks were compared between women delivering LGA and AGA infants. Predictors of LGA infants were sought for. Infant growth was followed until 3 months postdelivery. Results: In total, 53% (n = 59) delivered LGA infants. Mean glucose decreased during pregnancy in both groups, with women delivering LGA infants having a 0.4 mmol/L higher mean glucose from 11-33 weeks (P = 0.01) compared with women delivering AGA infants. Mean TIRp >70% was obtained from 34 weeks in women delivering LGA infants and from 22-33 weeks in women delivering AGA infants. Independent predictors for delivering LGA infants were mean glucose throughout pregnancy and gestational weight gain. At 3 months postdelivery, infant weight was higher in infants born LGA compared with infants born AGA (6360 g ± 784 and 5988 ± 894, P = 0.04). Conclusions/interpretations: Women with T1D delivering LGA infants achieved glycemic targets later than women delivering AGA infants. Mean glucose and gestational weight gain were independent predictors for delivering LGA infants. Infants born LGA remained larger postdelivery compared with infants born AGA.
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Affiliation(s)
- Julie Carstens Søholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Sidse K Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Kirsten Nørgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Tine D Clausen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Szmuilowicz ED, Barbour L, Brown FM, Durnwald C, Feig DS, O'Malley G, Polsky S, Aleppo G. Continuous Glucose Monitoring Metrics for Pregnancies Complicated by Diabetes: Critical Appraisal of Current Evidence. J Diabetes Sci Technol 2024:19322968241239341. [PMID: 38606830 DOI: 10.1177/19322968241239341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Ascertaining the utility of continuous glucose monitoring (CGM) in pregnancy complicated by diabetes is a rapidly evolving area, as the prevalence of type 1 diabetes (T1D), type 2 diabetes (T2D), and gestational diabetes mellitus (GDM) escalates. The seminal randomized controlled trial (RCT) evaluating CGM use added to standard care in pregnancy in T1D demonstrated significant improvements in maternal glycemia and neonatal health outcomes. Current clinical guidance recommends targets for percentage time in range (TIR), time above range (TAR), and time below range (TBR) during pregnancy complicated by T1D that are widely used in clinical practice. However, the superiority of CGM over blood glucose monitoring (BGM) is still questioned in both T2D and GDM, and whether glucose targets should be different than in T1D is unknown. Questions requiring additional research include which CGM metrics are superior in predicting clinical outcomes, how should pregnancy-specific CGM targets be defined, whether CGM targets should differ according to gestational age, and if CGM metrics during pregnancy should be similar across all types of diabetes. Limiting the potential for CGM to improve pregnancy outcomes may be our inability to maintain TIR > 70% throughout gestation, a goal achieved in the minority of patients studied. Adverse pregnancy outcomes remain high in women with T1D and T2D in pregnancy despite CGM technology, and this review explores the potential reasons and questions yet to be investigated.
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Affiliation(s)
| | - Linda Barbour
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | | | - Sarit Polsky
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Grazia Aleppo
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Zhou Z, Yao Y, Sun Y, Wang X, Huang S, Hou J, Wang L, Wei F. Serum betaine and dimethylglycine in mid-pregnancy and the risk of gestational diabetes mellitus: a case-control study. Endocrine 2024:10.1007/s12020-024-03732-4. [PMID: 38448678 DOI: 10.1007/s12020-024-03732-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/04/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE To investigate the associations of choline, betaine, dimethylglycine (DMG), L-carnitine, and Trimethylamine-N-oxide (TMAO) with the risk of Gestational diabetes mellitus (GDM) as well as the markers of glucose homeostasis. METHODS We performed a case-control study including 200 diagnosed GDM cases and 200 controls matched by maternal age (±2 years) and gestational age (±2 weeks). Concentrations of serum metabolites were measured by the high-performance liquid chromatography - tandem mass spectrometry (HPLC-MS/MS). RESULTS Compared to the control group, GDM group had significantly lower serum betaine concentration and betaine/choline ratio, and higher DMG concentration. Furthermore, decreased betaine concentration and betaine/choline ratio, increased DMG concentration showed significant association with the risk of GDM. In addition, serum betaine concentrations were negatively associated with blood glucose levels at 1-h post-glucose load (OGTT-1h), and both betaine and L-carnitine concentrations were positively associated with 1,5-anhydroglucitol levels. Betaine/choline ratio was negatively associated with OGTT-1h and blood glucose levels at 2-h post-glucose load (OGTT-2h) and serum choline concentrations were negatively associated with fasting blood glucose and positively associated with OGTT-2h. CONCLUSION Decreased serum betaine concentrations and betaine/choline ratio, and elevated DMG concentrations could be significant risk factors for GDM. Furthermore, betaine may be associated with blood glucose regulation and short-term glycemic fluctuations.
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Affiliation(s)
- Ziqing Zhou
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China
- The Genetics Laboratory, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Yao Yao
- The Genetics Laboratory, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Yanan Sun
- The Genetics Laboratory, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
- Medical Insurance Office of Shenzhen Longgang Central Hospital, Shenzhen, Guangdong Province, China
| | - Xin Wang
- The Genetics Laboratory, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
- Jiamusi University, Jiamusi, Heilongjiang Province, China
| | - Shang Huang
- The Genetics Laboratory, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
- Shenzhen Children's Hospital of China Medical University, Shenzhen, Guangdong Province, China
| | - Jianli Hou
- Department of Gynecology and Obstetrics, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Lijun Wang
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, Guangdong Province, China.
| | - Fengxiang Wei
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China.
- The Genetics Laboratory, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China.
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Pham DQ, Thorsell A, Castorino K, Cobb B. A review of CONCEPTT study findings including subanalyses in pregnant women using continuous glucose monitoring with type 1 diabetes and their offspring. Endocr Connect 2024; 13:e230407. [PMID: 38010170 PMCID: PMC10831538 DOI: 10.1530/ec-23-0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/27/2023] [Indexed: 11/29/2023]
Abstract
The main objective of this article is to provide a comprehensive review of continuous glucose monitor (CGM) use in pregnant women with type 1 diabetes (T1D) from the CONCEPTT study including subanalyses. Literature search was accessed through MEDLINE (1966-September 2023) using the key terms: CONCEPTT, pregnancy, women, T1D, and CGM with limitations set to distinguish human subjects written in English. A total of 17 publications including one main clinical trial and 15 subanalyses have been published to date regarding the use of CGM in pregnant women with T1D which were conducted by a research group identified as the CONCEPTT Collaborative Group. While advances in maternal care have resulted in safer pregnancy for both the mother and child, women with preexisting T1D and pregnancy still experience higher rates of complications both in the short and long term. The use of CGM in pregnancy has not been studied extensively until more recently. The CONCEPTT clinical trial was a landmark study that involved several subanalyses. The main trial proved that CGM use in T1D pregnancy resulted in less hyperglycemia in the third trimester, reduced large for gestational age (LGA, >90th percentile), reduced neonatal intensive care unit admissions lasting longer than 24 h, and reduced neonatal hypoglycemia. Although subanalyses showed a variety of results including 'inconclusive' due to lack of prespecification, it is believed that CGM in T1D during pregnancy is to be recommended and used for overall improved outcomes.
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Affiliation(s)
- David Q Pham
- Western University of Health Sciences, College of Pharmacy, Pomona, California, USA
- Mary & Dick Allen Diabetes Center at Hoag Hospital, Newport Beach, California, USA
| | - Ashley Thorsell
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | | | - Brandon Cobb
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
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Lei M, Chen D, Ling P, Wang C, Yang D, Deng H, Yang X, Xu W, Yan J. Effect of artificial pancreas system use on glycaemic control among pregnant women with type 1 diabetes mellitus: A meta-analysis of randomized controlled trials. Diabetes Obes Metab 2024; 26:673-681. [PMID: 37953389 DOI: 10.1111/dom.15357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 11/14/2023]
Abstract
AIM To assess the efficacy of artificial pancreas systems (APS) use among pregnant women with type 1 diabetes mellitus (T1DM) by conducting a meta-analysis. METHODS We searched five databases, including EMBASE, Web of Science, PubMed, Cochrane Library and SCOPUS, for literature on APS use among pregnant women with T1DM before October 9, 2023. The primary endpoint was 24-hour time in range (TIR; 3.5-7.8 mmol/L). Secondary endpoints included glycaemic metrics for 24-hour (mean blood glucose [MBG], time above range [TAR], time below range [TBR]), and overnight TIR and TBR. RESULTS We identified four randomized controlled trials involving 164 participants; one study with 16 participants focused on overnight APS use, and the other three focused on 24-hour APS use. Compared with standard care, APS exhibited a favourable effect on 24-hour TIR (standard mean difference [SMD] = 0.53, 95% confidence interval [CI] 0.25, 0.80, P < 0.001), overnight TIR (SMD = 0.67, 95% CI 0.39, 0.95, P < 0.001), and overnight TBR (<3.5 mmol/L; SMD = -0.49, 95% CI -0.77, -0.21 P < 0.001), while there was no significant difference in 24-hour TAR, 24-hour TBR, or MBG between the two groups. We further conducted subgroup analyses after removing the trial focused on overnight APS use and showed that 24-hour APS use reduced not only the 24-hour TIR (SMD = 0.41, 95% CI 0.12, 0.71; P = 0.007) but also the 24-hour TBR (<2.8 mmol/L; SMD = -0.77, 95% CI -1.32, -0.23, P = 0.006). CONCLUSION Our findings suggest that APS might improve 24-hour TIR and overnight glycaemic control, and 24-hour APS use also significantly reduced 24-hour TBR (2.8 mmol/L) among pregnant women with T1DM.
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Affiliation(s)
- Mengyun Lei
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Danrui Chen
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ping Ling
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chaofan Wang
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Daizhi Yang
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongrong Deng
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xubin Yang
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wen Xu
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jinhua Yan
- Department of Endocrinology and Metabolism, Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Sobhani NC, Goemans S, Nguyen A, Chambers ME, Richley M, Gabby LC, Field N, Han CS, Ramos GA. Continuous glucose monitoring in pregnancies with type 1 diabetes: small increases in time-in-range improve maternal and perinatal outcomes. Am J Obstet Gynecol 2024:S0002-9378(24)00024-3. [PMID: 38242337 DOI: 10.1016/j.ajog.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Continuous glucose monitors provide detailed information regarding glycemic control in pregnant patients with type 1 diabetes. Little data have been published examining the association between continuous glucose monitor parameters and perinatal outcomes among gravidas with type 1 diabetes using continuous glucose monitors. OBJECTIVE This study aimed to examine the association between perinatal outcomes and time-in-range as assessed by continuous glucose monitors used in pregnant individuals with type 1 diabetes. We hypothesized that higher time-in-range would be associated with lower risk of adverse perinatal outcomes. STUDY DESIGN This multicenter retrospective cohort study included all gravidas with type 1 diabetes using continuous glucose monitors who delivered from 2020 to 2022 at 5 University of California sites. Only those with continuous glucose monitor target range set to 70 to 140 mg/dL (±10 mg/dL) were included. Time-in-range (%) was recorded at 12, 16, 20, 24, 28, and 32 weeks. The primary maternal and neonatal outcomes were preeclampsia and large for gestational age, defined as birthweight ≥95th percentile. Kruskal-Wallis tests were used to compare median time-in-range between those with and without the primary outcomes. Log-binomial regression was used to obtain risk ratios, with adjustment for microvascular disease and years with type 1 diabetes. RESULTS A total of 91 patients were included. Most used an insulin pump (81%) and did not have diabetic microvascular disease (72%). Median time since diagnosis of type 1 diabetes was 16 years, and median periconception hemoglobin A1c was 6.7%. Compared with those with preeclampsia, normotensive gravidas had significantly higher time-in-range at nearly every time point. A similar pattern was observed for those with normal-birthweight infants compared with large-for-gestational-age infants. On adjusted analyses, every 5-unit increase in time-in-range at 12 weeks was associated with 45% and 46% reductions in the risks of preeclampsia and large for gestational age, respectively (preeclampsia: adjusted risk ratio, 0.55; 95% confidence interval, 0.30-0.99; large for gestational age: adjusted risk ratio, 0.54; 95% confidence interval, 0.29-0.99). CONCLUSION Higher time-in-range is associated with lower risk of preeclampsia and large for gestational age. This association is observed early in gestation, when each 5-unit increase in time-in-range is associated with ∼50% reduction in the risk of these complications. These findings can be used to counsel patients regarding the risk of pregnancy complications at specific time-in-range values, and to encourage patients that even small improvements in time-in-range can have significant impact on pregnancy outcomes. Larger studies are needed to further explore these findings and to identify optimal time-in-range to reduce perinatal complication rates.
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Affiliation(s)
- Nasim C Sobhani
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA.
| | - Sophie Goemans
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, CA
| | - Antoinette Nguyen
- School of Medicine & Dentistry, University of Rochester, Rochester, NY
| | - Melissa E Chambers
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, University of California Irvine, Irvine, CA
| | - Michael Richley
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA
| | - Lauryn C Gabby
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, CA
| | - Nancy Field
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California Davis, Davis, CA
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA
| | - Gladys A Ramos
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, CA
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Sanusi AA, Xue Y, McIlwraith C, Howard H, Brocato BE, Casey B, Szychowski JM, Battarbee AN. Association of Continuous Glucose Monitoring Metrics With Pregnancy Outcomes in Patients With Preexisting Diabetes. Diabetes Care 2024; 47:89-96. [PMID: 37782847 PMCID: PMC10733654 DOI: 10.2337/dc23-0636] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/29/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVE Continuous glucose monitoring (CGM) improves maternal glycemic control and neonatal outcomes in type 1 diabetes pregnancies compared with self-monitoring of blood glucose. However, CGM targets for pregnancy are based on expert opinion. We aimed to evaluate the association between CGM metrics and perinatal outcomes and identify evidence-based targets to reduce morbidity. RESEARCH DESIGN AND METHODS This was a retrospective cohort study of pregnant patients with type 1 or 2 diabetes who used real-time CGM and delivered at a U.S. tertiary center (2018-2021). Multiple gestations, fetal anomalies, and early pregnancy loss were excluded. Exposures included time in range (TIR; 65-140 mg/dL), time above range (TAR), time below range (TBR), glucose variability, average glucose, and glucose management indicator. The primary outcome was a composite of fetal or neonatal mortality, large or small for gestational age at birth, neonatal intensive care unit admission, hypoglycemia, shoulder dystocia or birth trauma, and hyperbilirubinemia. Logistic regression estimated the association between CGM metrics and outcomes, and optimal TIR was calculated. RESULTS Of 117 patients, 16 (13.7%) used CGM before pregnancy and 68 (58.1%) had type 1 diabetes. Overall, 98 patients (83.8%) developed the composite neonatal outcome. All CGM metrics, except TBR, were associated with neonatal morbidity. For each 5 percentage-point increase in TIR, there was 28% reduced odds of neonatal morbidity (odds ratio 0.72, 95% CI 0.58-0.89). The statistically optimal TIR was 66-71%. CONCLUSIONS Nearly all CGM metrics were associated with adverse neonatal morbidity and mortality and may aid management of preexisting diabetes in pregnancy. Our findings support the American Diabetes Association recommendation of 70% TIR.
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Affiliation(s)
- Ayodeji A. Sanusi
- Center for Women’s Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Yumo Xue
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL
| | - Claire McIlwraith
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Hannah Howard
- School of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Brian E. Brocato
- Center for Women’s Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Brian Casey
- Center for Women’s Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Jeff M. Szychowski
- Center for Women’s Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Ashley N. Battarbee
- Center for Women’s Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
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Feig DS, Scott EM. Optimizing Patient Outcomes in Pregnancy: What Continuous Glucose Monitoring Metrics Should We Be Aiming For? Diabetes Care 2024; 47:54-55. [PMID: 38117998 DOI: 10.2337/dci23-0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 12/22/2023]
Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Sinai Health System, Mount Sinai Hospital, Toronto, Canada
| | - Eleanor M Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, U.K
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Sibiak R, Mantaj U, Gutaj P, Richard Law G, Wender-Ozegowska E. Functional analysis of daily glycemic profiles and excessive fetal growth in pregnant patients with well-controlled type 1 diabetes: Retrospective cohort. Diabetes Res Clin Pract 2024; 207:111088. [PMID: 38195042 DOI: 10.1016/j.diabres.2024.111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 01/11/2024]
Abstract
AIMS The study objective was to compare daily glycemic profiles throughout gestation between the mothers of large-for-gestational-age (LGA) and non-LGA newborns in patients with type 1 diabetes (T1D). METHODS We selected 102 eligible pregnant women who were treated with sensor-augmented pumps in our single-center retrospective cohort study. We used functional data analysis to compare glycemic control across gestation. RESULTS Median HbA1c values in the first, second, and third trimester were 6.23 %, 5.49 %, and 5.75 % respectively. Median time-in-range (TIR) exceeded 70 % in each trimester (72.4 %, 72.5 %, and 75.9 %, respectively). From 59 % up to 77 % of women met the criteria for well-controlled T1D defined by the mean HbA1c and TIR in each trimester. Despite that, 27 % (28/102) of pregnancies were complicated by LGA. Mothers of LGA infants had significantly increased HbA1c levels and decreased TIR values in the second and third trimesters. The most significant differences in daily mean glucose values between LGA and non-LGA newborns' mothers occurred between 26 and 32 weeks of pregnancy. These discrepancies were noted in daytime glucose values rather than nocturnal and fasting glucose levels. CONCLUSIONS Mothers of LGA newborns present significantly worse glycemic control. Our findings may emphasize the need for more rigorous daytime glycemic control.
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Affiliation(s)
- Rafal Sibiak
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland; Department of Histology and Embryology, Poznan University of Medical Sciences, Poznan, Poland; Doctoral School, Poznan University of Medical Sciences, Poznan, Poland.
| | - Urszula Mantaj
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - Pawel Gutaj
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Ewa Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
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McLean A, Barr E, Tabuai G, Murphy HR, Maple-Brown L. Continuous Glucose Monitoring Metrics in High-Risk Pregnant Women with Type 2 Diabetes. Diabetes Technol Ther 2023; 25:836-844. [PMID: 37902969 DOI: 10.1089/dia.2023.0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
Objective: To describe glucose metrics in a high-risk population of women with type 2 diabetes (T2DM) in pregnancy and to explore the associations with neonatal outcomes. Research Design and Methods: Prospective observational study of 57 women. Continuous glucose monitoring (CGM) trajectories were determined from metrics collected in early and late gestation using the first and last two (mean 16 and 35) weeks of Freestyle Libre data. Logistic regression was used to examine associations of CGM metrics with neonatal hypoglycemia (glucose <2.6 mmol/L requiring intravenous dextrose) and large for gestational age (LGA) (>90th percentile for gestational age and sex). Pregnancy-specific target glucose range was 3.5-7.8 mmol/L (63-140 mg/dL). Results: Forty-one women used CGM for 15 weeks (mean age 33 years, 73% Aboriginal or Torres Strait Islander, 32% living remotely). There was limited change in average metrics from early to late pregnancy. For the subgroup with sensor use >50% (n = 29), mean time in range (TIR) increased by 9%, time above range reduced by 12%, average glucose reduced by 1 mmol/L, and time below range increased by 3%. Neonatal hypoglycemia was associated with most CGM metrics, HbA1c and CGM targets, particularly those from late pregnancy. LGA was associated with hyperglycemic metrics from early pregnancy. Each 1% increase TIR was associated with a 4%-5% reduction in risk of neonatal complications. Conclusion: In this high-risk group of women with T2DM, CGM metrics only improved during pregnancy in those with greater sensor use and were associated with LGA in early pregnancy and neonatal hypoglycemia throughout. Culturally appropriate health care strategies are critical for successful use of CGM technology.
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Affiliation(s)
- Anna McLean
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Endocrinology Department, Cairns Hospital, Cairns, Australia
| | - Elizabeth Barr
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Georgina Tabuai
- Endocrinology Department, Cairns Hospital, Cairns, Australia
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Louise Maple-Brown
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Endocrinology Department, Royal Darwin Hospital, Darwin, Australia
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11
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Rademaker D, van der Wel AWT, van Eekelen R, Voormolen DN, de Valk HW, Evers IM, Mol BW, Franx A, Siegelaar SE, van Rijn BB, DeVries JH, Painter RC. Continuous glucose monitoring metrics and pregnancy outcomes in insulin-treated diabetes: A post-hoc analysis of the GlucoMOMS trial. Diabetes Obes Metab 2023; 25:3798-3806. [PMID: 37735847 DOI: 10.1111/dom.15276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/23/2023]
Abstract
AIM To investigate the association between continuous glucose monitoring (CGM) metrics and perinatal outcomes in insulin-treated diabetes mellitus in pregnancy. MATERIALS AND METHODS In a post-hoc analysis of the GlucoMOMS randomized controlled trial, we investigated the association between the metrics of an offline, intermittent CGM, glycated haemoglobin (HbA1c) and perinatal outcomes per trimester in different types of diabetes (type 1, 2 or insulin-treated gestational diabetes mellitus [GDM]). Data were analysed using multivariable binary logistic regression. Outcomes of interest were neonatal hypoglycaemia, pre-eclampsia, preterm birth, large for gestational age (LGA) and Neonatal Intensive Care Unit (NICU) admission. The glucose target range was defined as 3.5-7.8 mmol/L (63-140 mg/dL). RESULTS Of the 147 participants (N = 50 type 1 diabetes, N = 94 type 2 diabetes/insulin-treated GDM) randomized to the CGM group of the GlucoMOMS trial, 115 participants had CGM metrics available and were included in the current study. We found that, in pregnancies with type 1 diabetes, a higher second trimester mean glucose was associated with LGA (odds ratio 2.6 [95% confidence interval 1.1-6.2]). In type 2 and insulin-treated gestational diabetes, an increased area under the curve above limit was associated with LGA (odds ratio 10.0 [95% confidence interval 1.4-72.8]). None of the CGM metrics were associated with neonatal hypoglycaemia, pre-eclampsia, shoulder dystocia, preterm birth and NICU admission rates for pregnancies complicated by any type of diabetes. CONCLUSION In this study, in type 2 diabetes or insulin-treated GDM, the glucose increased area under the curve above limit was associated with increased LGA. In type 1 diabetes, the mean glucose was the major determinant of LGA. Our study found no evidence that other CGM metrics determined adverse pregnancy outcomes.
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Affiliation(s)
- Doortje Rademaker
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Anne W T van der Wel
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
| | - Rik van Eekelen
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
| | | | - Harold W de Valk
- Department of Endocrinology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Inge M Evers
- Department of Obstetrics and Gynecology, Amersfoort, The Netherlands
| | - Ben Willem Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Abderdeen, UK
| | - Arie Franx
- Department of Obstetrics and Gynecology, Erasmus University, Rotterdam, The Netherlands
| | - Sarah E Siegelaar
- Amsterdam UMC location University of Amsterdam, Department of Endocrinology and Metabolism, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Bas B van Rijn
- Department of Obstetrics and Gynecology, Erasmus University, Rotterdam, The Netherlands
| | - J Hans DeVries
- Amsterdam UMC location University of Amsterdam, Department of Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Rebecca C Painter
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
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12
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Murphy HR. Roadmap to the Effective Use of Continuous Glucose Monitoring in Pregnancy. Diabetes Spectr 2023; 36:315-319. [PMID: 37982059 PMCID: PMC10654120 DOI: 10.2337/dsi23-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
The landscape for managing type 1 diabetes during pregnancy has been transformed by increasing use of continuous glucose monitoring (CGM). Women are aiming for pregnancy-specific glucose targets or 70% time in range for pregnancy (TIRp; 63-140 mg/dL) as soon as possible, knowing that every extra 5% TIRp has benefits for reducing the risks of complications in their babies. Ongoing monitoring of maternal A1C (at pregnancy confirmation and at 20, 28, and 36 weeks' gestation) remains useful. Intensification of glycemic management and instruction in using CGM (if not already used) is recommended for individuals with an A1C >6.0% after 20 weeks. A better understanding of CGM-documented glycemic changes throughout pregnancy is needed to inform future management of gestational diabetes and pregnancy in people with type 2 diabetes. Research regarding overcoming barriers to CGM use and optimal TIRp targets for pregnant individuals with type 2 diabetes from diverse racial/ethnic groups is urgently needed.
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Affiliation(s)
- Helen R. Murphy
- Norwich Medical School, University of East Anglia, Norwich, U.K., and Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, U.K
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13
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Meek CL, Stewart ZA, Feig DS, Furse S, Neoh SL, Koulman A, Murphy HR. Metabolomic insights into maternal and neonatal complications in pregnancies affected by type 1 diabetes. Diabetologia 2023; 66:2101-2116. [PMID: 37615689 PMCID: PMC10542716 DOI: 10.1007/s00125-023-05989-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/19/2023] [Indexed: 08/25/2023]
Abstract
AIMS/HYPOTHESIS Type 1 diabetes in pregnancy is associated with suboptimal pregnancy outcomes, attributed to maternal hyperglycaemia and offspring hyperinsulinism (quantifiable by cord blood C-peptide). We assessed metabolomic patterns associated with risk factors (maternal hyperglycaemia, diet, BMI, weight gain) and perinatal complications (pre-eclampsia, large for gestational age [LGA], neonatal hypoglycaemia, hyperinsulinism) in the Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Trial (CONCEPTT). METHODS A total of 174 CONCEPTT participants gave ≥1 non-fasting serum sample for the biorepository at 12 gestational weeks (147 women), 24 weeks (167 women) and 34 weeks (160 women) with cord blood from 93 infants. Results from untargeted metabolite analysis (ultrahigh performance LC-MS) are presented as adjusted logistic/linear regression of maternal and cord blood metabolites, risk factors and perinatal complications using a modified Bonferroni limit of significance for dependent variables. RESULTS Maternal continuous glucose monitoring time-above-range (but not BMI or excessive gestational weight gain) was associated with increased triacylglycerols in maternal blood and increased carnitines in cord blood. LGA, adiposity, neonatal hypoglycaemia and offspring hyperinsulinism showed distinct metabolite profiles. LGA was associated with increased carnitines, steroid hormones and lipid metabolites, predominantly in the third trimester. However, neonatal hypoglycaemia and offspring hyperinsulinism were both associated with metabolite changes from the first trimester, featuring triacylglycerols or dietary phenols. Pre-eclampsia was associated with increased abundance of phosphatidylethanolamines, a membrane phospholipid, at 24 weeks. CONCLUSIONS/INTERPRETATION Altered lipid metabolism is a key pathophysiological feature of type 1 diabetes pregnancy. New strategies for optimising maternal diet and insulin dosing from the first trimester are needed to improve pregnancy outcomes in type 1 diabetes.
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Affiliation(s)
- Claire L Meek
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Zoe A Stewart
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Denice S Feig
- Mount Sinai Hospital, Sinai Health System, New York, NY, USA
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - Samuel Furse
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Core Metabolomics and Lipidomics Laboratory, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Sandra L Neoh
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Endocrinology, Northern Health, Melbourne, VIC, Australia
| | - Albert Koulman
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Core Metabolomics and Lipidomics Laboratory, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Helen R Murphy
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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14
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Meek CL. An unwelcome inheritance: childhood obesity after diabetes in pregnancy. Diabetologia 2023; 66:1961-1970. [PMID: 37442824 PMCID: PMC10541526 DOI: 10.1007/s00125-023-05965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023]
Abstract
Diabetes in pregnancy affects 20 million women per year and is associated with increased risk of obesity in offspring, leading to insulin resistance and cardiometabolic disease. Despite the substantial public health ramifications, relatively little is known about the pathophysiological mechanisms underlying obesity in these high-risk children, which creates a barrier to successful intervention. While maternal glucose itself is undeniably a major stimulus upon intrauterine growth, the degree of offspring hyperinsulinism and disturbed lipid metabolism in mothers and offspring are also likely to be implicated in the disease process. The aim of this review is to summarise current understanding of the pathophysiology of childhood obesity after intrauterine exposure to maternal hyperglycaemia and to highlight possible opportunities for intervention. I present here a new unified hypothesis for the pathophysiology of childhood obesity in infants born to mothers with diabetes, which involves self-perpetuating twin cycles of pancreatic beta cell hyperfunction and altered lipid metabolism, both acutely and chronically upregulated by intrauterine exposure to maternal hyperglycaemia.
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Affiliation(s)
- Claire L Meek
- Wellcome Trust MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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15
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Benhalima K, Beunen K, Siegelaar SE, Painter R, Murphy HR, Feig DS, Donovan LE, Polsky S, Buschur E, Levy CJ, Kudva YC, Battelino T, Ringholm L, Mathiesen ER, Mathieu C. Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets. Lancet Diabetes Endocrinol 2023; 11:490-508. [PMID: 37290466 DOI: 10.1016/s2213-8587(23)00116-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 06/10/2023]
Abstract
Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.
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Affiliation(s)
- Katrien Benhalima
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Kaat Beunen
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah E Siegelaar
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Rebecca Painter
- Department of Gynaecology and Obstetrics, Amsterdam UMC, Vrije Universiteit, Netherlands; Amsterdam Reproduction and Development, Amsterdam, Netherlands
| | - Helen R Murphy
- Diabetes and Antenatal Care, University of East Anglia, Norwich, UK
| | - Denice S Feig
- Department of Medicine, Obstetrics, and Gynecology and Department of Health Policy, Management, and Evaluation, University of Toronto, Diabetes and Endocrinology in Pregnancy Program, Mt Sinai Hospital, Toronto, ON, Canada
| | - Lois E Donovan
- Division of Endocrinology and Metabolism, Department of Medicine, and Department of Obstetrics and Gynaecology, Cumming School Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarit Polsky
- Medicine and Pediatrics, Barbara Davis Center for Diabetes, Adult Clinic, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Buschur
- Internal Medicine, Endocrinology, Diabetes, and Metabolism, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Carol J Levy
- Department of Medicine, Endocrinology and Obstetrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yogish C Kudva
- Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
| | | | - Chantal Mathieu
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
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16
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Boswell L, Perea V, Amor AJ, Seguí N, Bellart J, Roca D, Giménez M, Conget I, Vinagre I. Impaired hypoglycaemia awareness in early pregnancy increases risk of severe hypoglycaemia in the mid-long term postpartum irrespective of breastfeeding status in women with type 1 diabetes. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 2:18-26. [PMID: 37268354 DOI: 10.1016/j.endien.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/14/2022] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Information regarding the postpartum period in women with type 1 diabetes (T1D) is scarce. We aim to evaluate the relation of impaired hypoglycaemia awareness (IAH) in early pregnancy and breastfeeding status (its presence and duration) with severe postpartum hypoglycaemia (SH). MATERIALS AND METHODS Retrospective cohort study of women with T1D followed during pregnancy between 2012 and 2019. Data on SH were recorded before and during pregnancy. IAH was evaluated at the first antenatal visit. Data on breastfeeding and the long-term postpartum period were collected by questionnaire and from medical records. RESULTS A total of 89 women with T1D were included with a median follow-up after pregnancy of 19.2 [8.7-30.5] months. Twenty-eight (32%) women had IAH at the first antenatal visit. At discharge, 74 (83%) started breastfeeding during a median of 8 [4.4-15] months. A total of 18 (22%) women experienced ≥1 SH during postpartum. The incidence of SH significantly increased from pregestational to the gestational and post-partum period (0.09, 0.15 and 0.25 episodes/patient-year, respectively). Postpartum SH rates were comparable in breastfeeding and non-breastfeeding women (21.4% vs. 25%, respectively, p>0.05). Clarke test score at the first antenatal visit was associated with postpartum SH (for each 1-point increase: OR 1.53; 95% CI, 1.06-2.21) adjusted for confounders. No other diabetes and pregnancy-related variables were identified as predictors of SH in this period. CONCLUSIONS SH are common in the long-term postpartum period independently of breastfeeding. Assessing IAH in early pregnancy could identify those at an increased risk of SH in the postpartum period.
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Affiliation(s)
- Laura Boswell
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; Endocrinology and Nutrition Department, Althaia University Health Network, Manresa, Spain
| | - Verónica Perea
- Endocrinology Department, Hospital Universitari Mútua de Terrassa, Terrassa, Spain.
| | - Antonio J Amor
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Núria Seguí
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Bellart
- Obstetrics and Gynecology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Daria Roca
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marga Giménez
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Ignacio Conget
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Irene Vinagre
- Endocrinology and Nutrition Department, Hospital Clínic de Barcelona, Barcelona, Spain.
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Baretić M, Lekšić G, Ivanišević M. Ambulatory Glucose Profile Changes During Pregnancy in Women With Type 1 Diabetes Using Intermittently Scanned Continuous Glucose Monitoring Empowered by Personalized Education. Diabetes Spectr 2023; 36:373-378. [PMID: 38024224 PMCID: PMC10654119 DOI: 10.2337/ds22-0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
The ambulatory glucose profile is a valuable tool in managing type 1 diabetes during pregnancy. Time in range (TIR) in the third trimester is one of the most significant parameters contributing to good pregnancy outcomes. This study aimed to evaluate the effect of intermittently scanned continuous glucose monitoring (isCGM) empowered by education on glucose dynamics and to predict third trimester TIR. Data were retrospectively analyzed from 38 pregnant patients with type 1 diabetes (mean age 30.4 ± 6.4 years, BMI 23.7 ± 3.7 kg/m2, disease duration 15.4 ± 9.5 years, preconception A1C 6.9 ± 1%) who used a first-generation FreeStyle Libre isCGM system for at least 3 months before conception and had sensor data captured >70% of the time the system was used. Patients received personalized education on diabetes and on minimizing hypoglycemia and hyperglycemia using CGM trend arrows and frequent sensor scanning. This intervention improved glycemic parameters of glucose regulation (TIR, glucose management indicator, and mean glucose), hyperglycemia (time above range), glucose variability (SD and coefficient of variation [%CV]), and scanning frequency, but did not improve parameters of hypoglycemia (time below range and a number of low glucose events). Logistic regression analysis showed that the first trimester %CV and scanning frequency contributed to the third trimester TIR (P <0.01, adjusted R2 0.40). This study suggests that the use of isCGM empowered by personalized education improves glycemic control in pregnant women with type 1 diabetes. Scanning frequency and %CV in the first trimester predicts TIR in the third trimester, which could help clinicians intervene early to improve outcomes.
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Affiliation(s)
- Maja Baretić
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Gloria Lekšić
- Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marina Ivanišević
- University of Zagreb School of Medicine, Zagreb, Croatia
- Department of Gynaecology and Obstetrics, University Hospital Centre Zagreb, Zagreb, Croatia
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18
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Bogdanet D, Castillo MT, Doheny H, Dervan L, Luque-Fernandez MA, Halperin JA, O’Shea PM, Dunne FP. The ability of pGCD59 to predict adverse pregnancy outcomes: a prospective study of non-diabetic pregnant women in Ireland. Acta Diabetol 2023; 60:211-223. [PMID: 36309618 PMCID: PMC9617525 DOI: 10.1007/s00592-022-01983-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023]
Abstract
AIM Even though most pregnancies are uneventful, occasionally complications do occur. Gestational diabetes is linked to an increased risk of adverse pregnancy outcomes. Early identification of women at risk of experiencing adverse outcomes, ideally through a single blood test, would facilitate early intervention. Plasma glycated CD59 (pGCD59) is an emerging biomarker which has shown promise in identifying hyperglycaemia during pregnancy and has been associated with the risk of delivering an LGA infant. The aim of this study was to explore the ability of the first- and second-trimester pGCD59 to predict adverse pregnancy outcomes. METHODS This was a prospective study of 378 pregnant women. Samples for pGCD59 were taken at the first antenatal visit and at the time of the 2 h 75 g OGTT (24-28 weeks of gestation). Adjusted receiver operating characteristic curves were used to evaluate the ability of pGCD59 to predict maternal and neonatal outcomes. RESULTS First-trimester pGCD59 levels were higher in women with gestational diabetes who delivered a macrosomic infant (4.2 ± 0.7 vs. 3.5 ± 1.0 SPU, p < 0.01) or an LGA infant (4.3 ± 0.3 vs. 3.6 ± 1.0 SPU, p = 0.01) compared to women with GDM that did not experience these outcomes. Second-trimester pGCD59 levels were higher in women that developed polyhydramnios (2.9 ± 0.4 vs. 2.5 ± 1.1 SPU, p = 0.03). First- and second-trimester pGCD59 predicted pregnancy-induced hypertension with good accuracy (AUC:0.85, 95%CI:0.78-0.91; AUC: 0.80, 95%CI: 0.73-0.88, respectively) and neonatal hypoglycaemia with fair to good accuracy (AUC:0.77, 95%CI: 0.54-0.99, AUC:0.81, 95%CI:0.62-0.99). CONCLUSIONS This study has shown that pGCD59 has the potential to predict adverse pregnancy outcomes. Prospective studies with a larger number of cases are necessary to fully explore and validate the potential of this emerging biomarker in predicting adverse pregnancy outcomes.
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Affiliation(s)
- Delia Bogdanet
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland
| | - Michelle Toth Castillo
- Divisions of Haematology, Brigham & Women’s Hospital, Harvard Medical School, Boston, USA
| | - Helen Doheny
- Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - Louise Dervan
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland
| | - Miguel Angel Luque-Fernandez
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA USA
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jose A. Halperin
- Divisions of Haematology, Brigham & Women’s Hospital, Harvard Medical School, Boston, USA
| | - Paula M. O’Shea
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland
- Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland
| | - Fidelma P. Dunne
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland
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19
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Oliver N, Chow E, Luk AOY, Murphy HR. Applications of continuous glucose monitoring across settings and populations: Report from the 23rd Hong Kong diabetes and cardiovascular risk factors-East meets west symposium. Diabet Med 2023; 40:e15038. [PMID: 36617376 DOI: 10.1111/dme.15038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/18/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
Continuous glucose monitoring (CGM) is now an integral part of glycaemic management in people with type 1 diabetes and those with insulin-treated type 2 diabetes. Immediate access to information on CGM glucose levels and trends helps to inform food choices, titration and timing of insulin doses and prompts corrective actions in the event of impending hypo- or hyperglycaemia. Although glycated haemoglobin (HbA1c) remains an important measure of the average of glucose, CGM metrics including time-in-range (TIR) and other metrics on glycaemic variability and hypoglycaemia are strongly endorsed by people with diabetes as impacting their daily lives. There is growing consensus on definitions and targets of CGM metrics with an increasing number of studies demonstrating correlations between CGM metrics and incident complications of diabetes. Implementation of new technologies needs to take into consideration factors such as cost-effectiveness, accessibility as well as acceptability of the person with diabetes and healthcare professional. The United Kingdom is one of the few countries that have developed clinical pathways for integrating CGM into the routine care of people with type 1 diabetes. Besides type 1 diabetes, special groups such as people with impaired kidney function and women during pregnancy may derive additional benefits from CGM.
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Affiliation(s)
- Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, England
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Andrea O Y Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Helen R Murphy
- Cambridge University, NHS Foundation Trust, Cambridge, England
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Dingena CF, Holmes MJ, Campbell MD, Cade JE, Scott EM, Zulyniak MA. Observational assessments of the relationship of dietary and pharmacological treatment on continuous measures of dysglycemia over 24 hours in women with gestational diabetes. Front Endocrinol (Lausanne) 2023; 14:1065985. [PMID: 36777347 PMCID: PMC9909093 DOI: 10.3389/fendo.2023.1065985] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES Studies that use continuous glucose monitoring (CGM) to monitor women with gestational diabetes (GDM), highlight the importance of managing dysglycemia over a 24-hour period. However, the effect of current treatment methods on dysglycemia over 24-hrs are currently unknown. This study aimed to characterise CGM metrics over 24-hrs in women with GDM and the moderating effect of treatment strategy. METHODS Retrospective analysis of CGM data from 128 women with GDM in antenatal diabetes clinics. CGM was measured for 7-days between 30-32 weeks gestation. Non-parametric tests were used to evaluate differences of CGM between periods of day (morning, afternoon, evening, and overnight) and between treatment methods (i.e., diet alone or diet+metformin). Exploratory analysis in a subgroup of 34 of participants was performed to investigate the association between self-reported macronutrient intake and glycaemic control. RESULTS Glucose levels significantly differed during the day (i.e., morning to evening; P<0.001) and were significantly higher (i.e., mean blood glucose and area under the curve [AUC]) and more variable (i.e., SD and CV) than overnight glucose levels. Morning showed the highest amount of variability (CV; 8.4% vs 6.5%, P<0.001 and SD; 0.49 mmol/L vs 0.38 mmol/L, P<0.001). When comparing treatment methods, mean glucose (6.09 vs 5.65 mmol/L; P<0.001) and AUC (8760.8 vs 8115.1 mmol/L.hr; P<0.001) were significantly higher in diet+metformin compared to diet alone. Finally, the exploratory analysis revealed a favourable association between higher protein intake (+1SD or +92 kcal/day) and lower mean glucose (-0.91 mmol/L p, P=0.02) and total AUC (1209.6 mmol/L.h, P=0.021). CONCLUSIONS Glycemia varies considerably across a day, with morning glycemia demonstrating greatest variability. Additionally, our work supports that individuals assigned to diet+metformin have greater difficulty managing glycemia and results suggest that increased dietary protein may assist with management of dysglycemia. Future work is needed to investigate the benefit of increased protein intake on management of dysglycemia.
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Affiliation(s)
- Cassy F. Dingena
- Nutritional Epidemiology, School of Food Science and Nutrition, University of Leeds, Leeds, United Kingdom
| | - Melvin J. Holmes
- Nutritional Epidemiology, School of Food Science and Nutrition, University of Leeds, Leeds, United Kingdom
| | - Matthew D. Campbell
- School of Nursing and Health Sciences, Institute of Health Sciences and Wellbeing, University of Sunderland, Sunderland, United Kingdom
| | - Janet E. Cade
- Nutritional Epidemiology, School of Food Science and Nutrition, University of Leeds, Leeds, United Kingdom
| | - Eleanor M. Scott
- Department of Clinical and Population Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Michael A. Zulyniak
- Nutritional Epidemiology, School of Food Science and Nutrition, University of Leeds, Leeds, United Kingdom
- *Correspondence: Michael A. Zulyniak,
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21
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Bogdanet D, Luque-Fernandez MA, Toth-Castillo M, Desoye G, O’Shea PM, Dunne FP, Halperin JA. The Role of Early Pregnancy Maternal pGCD59 Levels in Predicting Neonatal Hypoglycemia-Subanalysis of the DALI Study. J Clin Endocrinol Metab 2022; 107:e4311-e4319. [PMID: 36054347 PMCID: PMC9681607 DOI: 10.1210/clinem/dgac498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Neonatal hypoglycaemia (NH) is the most common metabolic problem in infants born of mothers with gestational diabetes. Plasma glycated CD59 (pGCD59) is an emerging biomarker that has shown potential in identifying women at risk of developing gestational diabetes. The aim of this study was to assess the association between early maternal levels of pGCD59 and NH. OBJECTIVE The aim of this study was to assess the association between early pregnancy maternal levels of plasma glycated CD59 (pGCD59) and neonatal hypoglycemia (NH). METHODS This is an observational study of pregnant women with a prepregnancy body mass index (BMI) greater than or equal to 29 screened for eligibility to participate in the Vitamin D and Lifestyle Intervention for Gestational Diabetes (DALI) trial. This analysis included 399 pregnancies. Levels of pGCD59 were measured in fasting maternal samples taken at the time of a 75-g, 2-hour oral glucose tolerance test performed in early pregnancy (< 20 weeks). NH, the study outcome, was defined as a heel-prick capillary glucose level of less than 2.6 mmol/L within 48 hours of delivery. RESULTS We identified 30 infants with NH. Maternal levels of pGCD59 in early pregnancy were positively associated with the prevalence of NH (one-way analysis of variance, P < .001). The odds of NH were higher in infants from mothers in tertile 3 of pGCD59 levels compared to those from mothers in tertile 1 (odds ratio [OR]: 2.41; 95% CI, 1.03-5.63). However, this was attenuated when adjusted for maternal BMI (OR: 2.28; 95% CI, 0.96-5.43). The cross-validated area under the curve (AUC) was 0.64 (95% CI, 0.54-0.74), and adjusted for maternal BMI, age, and ethnicity, the AUC was 0.70 (95% CI, 0.56-0.78). CONCLUSION Although pGCD59 levels in early pregnancy in women with BMI greater than or equal to 29 are associated with NH, our results indicate that this biomarker by itself is only a fair predictor of NH.
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Affiliation(s)
- Delia Bogdanet
- Correspondence: Delia Bogdanet, MSc, College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Newcastle Road, Galway, Ireland.
| | - Miguel Angel Luque-Fernandez
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London KT12EE, UK
| | - Michelle Toth-Castillo
- Division of Hematology, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Gernot Desoye
- Department of Obstetrics and Gynecology, Medizinische Universitaet Graz, Graz A8036, Austria
| | - Paula M O’Shea
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway H91TK33, Ireland
- Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway H91YR71, Ireland
| | - Fidelma P Dunne
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway H91TK33, Ireland
| | - Jose A Halperin
- Division of Hematology, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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22
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Feig DS. Epidemiology and Therapeutic Strategies for Women With Preexisting Diabetes in Pregnancy: How Far Have We Come? The 2021 Norbert Freinkel Award Lecture. Diabetes Care 2022; 45:2484-2491. [PMID: 37579297 DOI: 10.2337/dci21-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
The field of diabetes in pregnancy has witnessed tremendous changes over the past 30 years, with an explosive growth in case numbers along with new and exciting opportunities to affect outcomes. Type 1 diabetes in pregnancy has increased by 40%, but type 2 diabetes in pregnancy, rarely seen 30 years ago, has more than doubled and, in some cases, tripled in prevalence. Compared with women with type 2 diabetes, women with type 1 diabetes have higher HbA1c, more large-for-gestational-age infants, and more preterm births. Women with type 2 diabetes have more chronic hypertension, more socioeconomic deprivation, and higher rates of perinatal mortality. Large randomized trials in women with diabetes in pregnancy have helped us understand the effectiveness of new technologies (i.e., continuous glucose monitoring) in women with type 1 diabetes, and the addition of metformin to insulin in women with type 2 diabetes, in improving pregnancy outcomes. Future endeavors, including artificial pancreas systems in women with type 1 diabetes and the use of continuous glucose monitoring, a better understanding of nutrition during pregnancy, and approaches to improve preconception and pregnancy self-care in women with type 2 diabetes, may lead to further improved outcomes.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
- Sinai Health System, Mount Sinai Hospital, Toronto, Canada
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23
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Perea V, Picón MJ, Megia A, Goya M, Wägner AM, Vega B, Seguí N, Montañez MD, Vinagre I. Addition of intermittently scanned continuous glucose monitoring to standard care in a cohort of pregnant women with type 1 diabetes: effect on glycaemic control and pregnancy outcomes. Diabetologia 2022; 65:1302-1314. [PMID: 35546211 DOI: 10.1007/s00125-022-05717-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/30/2022] [Indexed: 11/03/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to assess whether the addition of intermittently scanned continuous glucose monitoring (isCGM) to standard care (self-monitoring of blood glucose [SMBG] alone) improves glycaemic control and pregnancy outcomes in women with type 1 diabetes and multiple daily injections. METHODS This was a multicentre observational cohort study of 300 pregnant women with type 1 diabetes in Spain, including 168 women using SMBG (standard care) and 132 women using isCGM in addition to standard care. In addition to HbA1c, the time in range (TIR), time below range (TBR) and time above range (TAR) with regard to the pregnancy glucose target range (3.5-7.8 mmol/l) were also evaluated in women using isCGM. Logistic regression models were performed for adverse pregnancy outcomes adjusted for baseline maternal characteristics and centre. RESULTS The isCGM group had a lower median HbA1c in the second trimester than the SMBG group (41.0 [IQR 35.5-46.4] vs 43.2 [IQR 37.7-47.5] mmol/mol, 5.9% [IQR 5.4-6.4%] vs 6.1% [IQR 5.6-6.5%]; p=0.034), with no differences between the groups in the other trimesters (SMBG vs isCGM: first trimester 47.5 [IQR 42.1-54.1] vs 45.9 [IQR 39.9-51.9] mmol/mol, 6.5% [IQR 6.0-7.1%] vs 6.4% [IQR 5.8-6.9%]; third trimester 43.2 [IQR 39.9-47.5] vs 43.2 [IQR 39.9-47.5] mmol/mol, 6.1% [IQR 5.8-6.5%] vs 6.1% [IQR 5.7-6.5%]). The whole cohort showed a slight increase in HbA1c from the second to the third trimester, with a significantly higher rise in the isCGM group than in the SMBG group (median difference 2.2 vs 1.1 mmol/mol [0.2% vs 0.1%]; p=0.033). Regarding neonatal outcomes, newborns of women using isCGM were more likely to have neonatal hypoglycaemia than newborns of non-sensor users (27.4% vs 19.1%; ORadjusted 2.20 [95% CI 1.14, 4.30]), whereas there were no differences between the groups in large-for-gestational-age (LGA) infants (40.6% vs 45.1%; ORadjusted 0.73 [95% CI 0.42, 1.25]), Caesarean section (57.6% vs 48.8%; ORadjusted 1.33 [95% CI 0.78, 2.27]) or prematurity (27.3% vs 24.8%; ORadjusted 1.05 [95% CI 0.55, 1.99]) in the adjusted models. A sensitivity analysis in pregnancies without LGA infants or prematurity also showed that the use of isCGM was associated with a higher risk of neonatal hypoglycaemia (non-LGA: ORadjusted 2.63 [95% CI 1.01, 6.91]; non-prematurity: ORadjusted 2.52 [95% CI 1.12, 5.67]). For isCGM users, the risk of delivering an LGA infant was associated with TIR, TAR and TBR in the second trimester in the logistic regression analysis. CONCLUSIONS/INTERPRETATION isCGM use provided an initial improvement in glycaemic control that was not sustained. Furthermore, offspring of isCGM users were more likely to have neonatal hypoglycaemia, with similar rates of macrosomia and prematurity to those of women receiving standard care.
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Affiliation(s)
- Verónica Perea
- Endocrinology Department, Hospital Universitari Mútua de Terrassa, Barcelona, Spain.
| | - Maria José Picón
- Endocrinology Department, Hospital Universitario Virgen de la Victoria, IBIMA, Málaga, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Ana Megia
- Endocrinology Department, Hospital Universitari Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Maria Goya
- Obstetrics and Gynaecology Department, Hospital Universitari Vall d' Hebrón, Barcelona, Spain
| | - Ana Maria Wägner
- Endocrinology Department, Complejo Hospitalario Universitario Insular Materno Infantil de Canarias, Las Palmas de Gran Canaria, Spain
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias (IUIBS), Universidad de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Begoña Vega
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias (IUIBS), Universidad de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
- Obstetrics and Gynaecology Department, Complejo Hospitalario Universitario Insular Materno Infantil de Canarias, Las Palmas de Gran Canaria, Spain
| | - Nuria Seguí
- Diabetes Unit, Endocrinology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Irene Vinagre
- Diabetes Unit, Endocrinology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
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Bogdanet D, Toth Castillo M, Doheny H, Dervan L, Angel Luque-Fernandez M, Halperin J, O'Shea PM, Dunne FP. The utility of first trimester plasma glycated CD59 (pGCD59) in predicting gestational diabetes mellitus: A prospective study of non-diabetic pregnant women in Ireland. Diabetes Res Clin Pract 2022; 190:110023. [PMID: 35907507 PMCID: PMC9483034 DOI: 10.1016/j.diabres.2022.110023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 12/02/2022]
Abstract
AIMS To evaluate the ability of first trimester plasma glycated CD59 (pGCD59) to predict gestational diabetes mellitus (GDM) at 24-28 weeks of gestation. METHODS Prospectively, in 378 pregnant women, GDM was diagnosed using the one step 2 h 75 g oral glucose tolerance test adjudicated by the World Health Organisation (WHO) 2013 criteria. The ability of pGCD59 to predict GDM was assessed using receiver operating characteristic (ROC) curves adjusted for maternal age, body mass index (BMI), maternal ethnicity, parity, previous GDM, family history of diabetes mellitus and week of gestation at time of pGCD59 sampling. RESULTS pGCD59 generated an adjusted area under the curve (AUC) of (a) 0.63 (95 %CI:0.56-0.70, p < 0.001) for predicting GDM, and (b) 0.71 (95 %CI:0.62-0.79, p < 0.001 for GDM diagnosed with a fasting plasma glucose (FPG) ≥ 5.1 mmol/L. Sensitivity analysis of BMI subgroups showed that pGCD59 generated the highest AUC in the 35 kg/m2 ≤ BMI < 40 kg/m2 (AUC:0.85, 95 %CI:0.70-0.98) and BMI ≥ 40 kg/m2 (AUC:0.88, 95 %CI:0.63-0.99) categories. CONCLUSIONS Early in pregnancy, pGCD59 may be a good predictor of GDM in women with a high BMI and a fair predictor of GDM diagnosed by an elevated FPG independent of BMI.
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Affiliation(s)
- Delia Bogdanet
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland.
| | - Michelle Toth Castillo
- Divisions of Haematology, Brigham & Women's Hospital, Harvard Medical School, United States.
| | - Helen Doheny
- Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland.
| | - Louise Dervan
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland.
| | - Miguel Angel Luque-Fernandez
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Jose Halperin
- Divisions of Haematology, Brigham & Women's Hospital, Harvard Medical School, United States.
| | - Paula M O'Shea
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland; Department of Clinical Biochemistry, Saolta University Health Care Group (SUHCG), Galway University Hospitals, Galway, Ireland.
| | - Fidelma P Dunne
- College of Medicine, Nursing and Health Sciences, School of Medicine, National University of Ireland, Galway, Ireland.
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Scott EM, Murphy HR, Kristensen KH, Feig DS, Kjölhede K, Englund-Ögge L, Berntorp KE, Law GR. Continuous Glucose Monitoring Metrics and Birth Weight: Informing Management of Type 1 Diabetes Throughout Pregnancy. Diabetes Care 2022; 45:1724-1734. [PMID: 35696191 DOI: 10.2337/dc22-0078] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine gestational weekly changes in continuous glucose monitoring (CGM) metrics and 24-h glucose profiles and their relationship to infant birth weight in pregnant women with type 1 diabetes. RESEARCH DESIGN AND METHODS An analysis of >10.5 million CGM glucose measures from 386 pregnant women with type 1 diabetes from two international multicenter studies was performed. CGM glucose metrics and 24-h glucose profiles were calculated for each gestational week, and the relationship to normal (10-90th percentile) and large (>90th percentile) for gestational age (LGA) birth weight infants was determined. RESULTS Mean CGM glucose concentration fell and percentage of time spent in the pregnancy target range of 3.5-7.8 mmol/L (63-140 mg/dL) increased in the first 10 weeks of pregnancy and plateaued until 28 weeks of gestation, before further improvement in mean glucose and percentage of time in range until delivery. Maternal CGM glucose metrics diverged at 10 weeks of gestation, with significantly lower mean CGM glucose concentration (7.1 mmol/L; 95% CI 7.05-7.15 [127.8 mg/dL; 95% CI 126.9-128.7] vs. 7.5 mmol/L; 95% CI 7.45-7.55 [135 mg/dL; 95% CI 134.1-135.9]) and higher percentage of time in range (55%; 95% CI 54-56 vs. 50%; 95% CI 49-51) in women who had normal versus LGA. The 24-h glucose profiles were significantly higher across the day from 10 weeks of gestation in LGA. CONCLUSIONS Normal birth weight is associated with achieving significantly lower mean CGM glucose concentration across the 24-h day and higher CGM time in range from before the end of the first trimester, emphasizing the need for a shift in clinical management, with increased focus on using weekly CGM glucose targets for optimizing maternal glycemia from early pregnancy.
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Affiliation(s)
- Eleanor M Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, U.K
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, U.K
| | - Karl H Kristensen
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
| | - Denice S Feig
- Department of Medicine, University of Toronto, Sinai Health System, Toronto, Ontario, Canada
| | - Karin Kjölhede
- Department of Obstetrics and Gynecology, Östra/Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Englund-Ögge
- Department of Obstetrics and Gynecology, Östra/Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Graham R Law
- School of Health and Social Care, University of Lincoln, Lincoln, U.K
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Boswell L, Perea V, Amor AJ, Seguí N, Bellart J, Roca D, Giménez M, Conget I, Vinagre I. Impaired hypoglycaemia awareness in early pregnancy increases risk of severe hypoglycaemia in the mid-long term postpartum irrespective of breastfeeding status in women with type 1 diabetes. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sibiak R, Gutaj P, Mrzewka-Rogacz B, Mantaj U, Wender-Ozegowska E. Novel Continuous Glucose Monitoring Metrics and Large-for-Gestational-Age Risk: An Exploratory Retrospective Cohort Study in Pregnancies with Type 1 Diabetes. Diabetes Technol Ther 2022; 24:42-53. [PMID: 34524000 DOI: 10.1089/dia.2021.0194] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: Continuous glucose monitoring (CGM) improves pregnancy outcomes in patients with type 1 diabetes (T1D). We aimed to assess the between-group differences in glycated hemoglobin (HbA1c) and the incidence of large-for-gestational-age (LGA) neonates in CGM and glucometer users and analyze the potential association of novel CGM metrics with LGA risk in T1D pregnancies. Materials and Methods: Our retrospective study cohort included 134 women with T1D treated with insulin pumps-75 of them used CGM and 59 patients measured their glucose concentrations using glucometers only. As part of our study, we matched the CGM users and patients who preferred the self-monitoring of blood glucose (SMBG) according to their baseline HbA1c and White's diabetes class at a 1:1 ratio. After the matching, both groups included 42 pregnancies. Results: We did not find any difference in changes in HbA1c and perinatal outcomes between CGM and SMBG users; however, we achieved a limited statistical power, and there were more cases of diabetic nephropathy in the SMBG group. Mothers of LGA infants had higher first-trimester HbA1c, time above target, and mean glucose concentrations in each trimester of pregnancy. Other CGM metrics reflecting glucose fluctuations attributed to hyperglycemia were associated with an increased risk of LGA. Despite optimal maternal HbA1c, 39% of neonates demonstrated LGA. Conclusions: Although participants reached the target HbA1c concentrations, mothers of LGA newborns had higher first-trimester HbA1c, as well as higher time above target range, higher mean glucose concentrations, and more glycemic fluctuations, suggesting that several CGM metrics associated with maternal hyperglycemia are associated with LGA in pregnancies with T1D.
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Affiliation(s)
- Rafał Sibiak
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
- Department of Histology and Embryology, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Gutaj
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - Beata Mrzewka-Rogacz
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - Urszula Mantaj
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - Ewa Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
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Tundidor D, Meek CL, Yamamoto J, Martínez-Bru C, Gich I, Feig DS, Murphy HR, Corcoy R. Continuous Glucose Monitoring Time-in-Range and HbA 1c Targets in Pregnant Women with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:710-714. [PMID: 33945304 PMCID: PMC8573793 DOI: 10.1089/dia.2021.0073] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The CONCEPTT trial compared real-time Continuous Glucose Monitoring (RT-CGM) to capillary glucose monitoring in pregnant women with type 1 diabetes. We analyzed CGM and glycated hemoglobin (HbA1c) measures in first (n = 221), second (n = 197), and third (n = 172) trimesters, aiming to examine target glucose attainment and associations with pregnancy outcomes. CGM targets were Time-in-range (TIR) > 70%, Time-above-range (TAR) <25%, and Time-below-range (TBR) < 4%, and HbA1c targets < 6.5% (National Institute for Health and Care Excellence [NICE]) and HbA1c < 6.0% in second and third trimesters (American Diabetes Association [ADA]). TIR/TAR/TBR targets were achieved by 7.7/14.5/30.3% participants in first, 10.2/14.2/52.8% in second, and 35.5/37.2/52.9% in third trimesters. CGM target attainment was low but increased during pregnancy and with RT-CGM use. In the adjusted analyses, achieving TBR target was associated with a higher risk of pre-eclampsia and neonatal hypoglycemia. ADA HbA1c target attainment was low and unchanged during pregnancy (23.5/27.9/23.8%) but increased with RT-CGM use. In the adjusted analyses, HbA1c target attainment was associated with a lower risk of preterm birth, large-for-gestational age and neonatal hypoglycemia. We conclude that CONCEPTT trial participants had a low rate of CGM and of HbA1c target attainment. Attainment of CGM and NICE HbA1c targets increased throughout gestation and all targets (both NICE/ADA HbA1c and CGM) were more likely to be achieved by RT-CGM users, at 34 weeks' gestation. ADA HbA1c target achievement was independently associated with better perinatal outcomes, while the independent association of TBR target achievement with increased risk warrants further study. ClinicalTrials.gov Registration Identifier NCT01788527.
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Affiliation(s)
- Diana Tundidor
- Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Claire L Meek
- Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Cambridge Universities NHS Foundation Trust, Cambridge, United Kingdom
| | - Jennifer Yamamoto
- Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Ignasi Gich
- Department of Clinic Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Denice S Feig
- Mount Sinai Hospital, Sinai Health System, Department of Medicine, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- School of Life Course Sciences, King's College London, London, United Kingdom
| | - Rosa Corcoy
- Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Servei d'Endocrinologia i Nutrició, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER-BBN, Madrid, Spain
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Abstract
Despite recent advances in care, women with diabetes in pregnancy are still at increased risk of multiple pregnancy complications. Offspring exposed to hyperglycaemia in utero also experience long-term health sequelae, affecting neurocognitive and cardiometabolic status. Many of these adverse consequences can be prevented or ameliorated with good medical care, specifically to optimize glycaemic control. The accurate assessment of glycaemia in pregnancy is therefore vital to safeguard the health of mother and child. However, there is no consensus about the best method of monitoring glycaemic control in pregnancy. Short-term changes in insulin dosage and lifestyle, with altered appetite, insulin sensitivity and red cell turnover create difficulties in interpretation of standard laboratory measures such as HbA1c. The ideal marker would provide short-term feedback on daily or weekly glycaemic control, with additional capability to predict pregnancies at high risk of suboptimal outcomes. Several novel biochemical markers are available which allow assessment of dynamic changes in glycaemia over weeks rather than months. Continuous glucose monitoring devices have advanced in accuracy and provide new opportunities for robust assessment of glycaemia in pregnancy. Recent work from the continuous glucose monitoring in pregnant women with type 1 diabetes trial (CONCEPTT) has provided information about the ability of different markers of glycaemia to predict pregnancy outcomes.The aim of this review is to summarize the care for women with pre-existing diabetes in pregnancy and to highlight the important role of glycaemic monitoring in pregnancy.
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Affiliation(s)
- Claire L Meek
- Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.,Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK.,Department of Clinical Biochemistry, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
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30
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Affiliation(s)
- Claire L Meek
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Cambridge Universities NHS Foundation Trust, Cambridge, UK
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31
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Agnello L, Lo Sasso B, Scazzone C, Giglio RV, Gambino CM, Bivona G, Pantuso M, Ciaccio AM, Venezia R, Vidali M, Ciaccio M. Preliminary reference intervals of Glycated Albumin in healthy Caucasian pregnant women. Clin Chim Acta 2021; 519:227-230. [PMID: 33989612 DOI: 10.1016/j.cca.2021.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Glycated albumin (GA) could represent a useful biomarker in pregnant women for diagnosing and monitoring gestational diabetes mellitus (GDM). The establishment of reference intervals (RI) is mandatory before assessing its clinical usefulness. The RIs of GA in healthy pregnant women are not well defined. The aim of the current study was to establish the RI in a cohort consisting of Caucasian pregnant women without overt diabetes mellitus or gestational diabetes mellitus. METHODS The study included 183 healthy pregnant women. GA was measured on plasma by an enzymatic method (quantILab Glycated Albumin, IL Werfen, Germany). The RI was calculated by the non-parametric and robust methods. RESULTS The RI of GA in the whole population was 10.16% (90%CI 9.60-10.70) and 15.44% (90%CI 14.90-16.90). GA levels decreased during pregnancy, with lower levels in the third trimester: 10.11 (90%CI 9.48-10.79) and 15.72 (90%CI 15.15-16.27) in the first trimester, 10.49 (90%CI 10.05-10.96) and 15.49 (90%CI 15.05-15.92) in the second trimester, 9.84 (90%CI 9.50-10.22) and 14.57 (90%CI 14.11-15.01) in the third trimester. Finally, a weak negative correlation was found between GA levels and body mass index. CONCLUSION This is the first study establishing the RIs of GA in Caucasian healthy pregnant women.
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Affiliation(s)
- Luisa Agnello
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Bruna Lo Sasso
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy; Department of Laboratory Medicine, University Hospital "P. Giaccone", Palermo, Italy
| | - Concetta Scazzone
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Rosaria Vincenza Giglio
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Caterina Maria Gambino
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giulia Bivona
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Michele Pantuso
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | | | - Renato Venezia
- Unit of Gynaecology and Obstetrics, Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, Italy
| | - Matteo Vidali
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marcello Ciaccio
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy; Department of Laboratory Medicine, University Hospital "P. Giaccone", Palermo, Italy.
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