Oligomenorrhoea in adolescents with type 1 diabetes mellitus: relationship to glycaemic control

Objective

To investigate oligomenorrhoea in adolescents with type 1 diabetes and the possible relationship with glycaemic control.

Study design

The study group consisted of 81 female adolescents with type 1 diabetes whose mean age was 15.0 years (range 12-18). The control group consisted of 205 healthy adolescents with a mean age of 15.5 years (range 12-18). Data on menstruation were collected by two parallel self-administered questionnaires. Oligomenorrhoea was defined as having a menstrual cycle longer than 36 days throughout the past year (5-6/year). The metabolic control of diabetes was evaluated by calculating the mean value of HbA1c during the past year.

Results

Age of menarche was greater for adolescents with type 1 diabetes (12.2 ± 1.4 vs. 11.7 ± 1.2, p < 0.000) compared to healthy age-matched controls. Logistic regression analysis with oligomenorrhoea as the dependent binary variable revealed an odds ratio equal to 7.8 (95% CI 3.411-17.853) for adolescents with type 1 diabetes (p < 0.000). Finally, a second logistic regression analysis, concerning only adolescents with type 1 diabetes and with the same binary variable, estimated an odds ratio of 4.8 (95% CI 1.784-13.057, p < 0.002) for HbA1c, and an odds ratio of 5.3 (95% CI 1.821-15.130, p < 0.002) for the frequency of hypoglycaemia.

Conclusion

In adolescents with type 1 diabetes, menarche occurs later and oligomenorrhoea is more frequent. The relative risk of having oligomenorrhoea is greater when there is an increased value of HbA1c or when hypoglycaemia is more frequent.     

Perinatal outcomes in pregnancies complicated by type 1 diabetes mellitus

Abstract

The aim of this study was to explore the risk of perinatal outcomes in pre-gestational type 1 diabetes mellitus (T1DM) compared to gestational diabetes mellitus (GDM) and pregnancy without diabetes and to examine the association of glycemic level of third-trimester gestation with perinatal outcomes in T1DM. We included 69 pre-gestational T1DM, 1398 cases of GDM, and 1304 control pregnancies and collected data regarding demographics, obstetric, and perinatal outcomes from the hospital discharge database. Relative to the pregnancies without diabetes, women with T1DM encountered increasing risk of polyhydramnios, preterm delivery, and cesarean section. These adverse outcomes were also common in GDM, although with relatively lower adjusted ORs. The weights of babies delivered by women with T1DM were more intend to be large for gestational age, as well as to be less than 2.5?kg relative to those without diabetes. Poorly controlled hemoglobin A1c in late pregnancy was significantly associated with an increased risk of preterm birth in T1DM (adjusted odds ratio 2.01, 95%confidence interval 1.1–3.6). Women with T1DM have considerably increased risks of adverse perinatal outcomes, which appear more prevalent than the perinatal outcomes in women with GDM. Thus, a specific routine is required for pregnancy in T1DM to improve the glycemic control and obstetric care.     

Maternal overweight and pregnancy outcome in women with Type-1 diabetes mellitus and different degrees of nephropathy

Objective.?We aimed to assess the parameters associated with complicated pregnancy in women with Type 1 diabetes mellitus (DM) and nephropathy.

Study design.?A cohort study of 46 consecutive women diagnosed with Type 1 DM with nephropathy prior to pregnancy was included during the years 2000–2007. Complicated pregnancy was defined as one or more of the following: first trimester abortion, superimposed pre-eclampsia, pre-term delivery?<34 weeks, small and large for gestational age neonate, macrosomia, admission to the neonatal intensive care unit and foetal loss (after 22 weeks' gestation).

Results.?Overall, 31/46 (67%) had at least one pregnancy complication. Body mass index (BMI) was the only parameter with a significant difference between the groups, being higher in the women with complicated pregnancy vs. uncomplicated pregnancy (27?±?9 vs. 24?±?3, p?=?0.027). On Multiple logistic regression model in which composite outcome (pregnancy complication) as the dependent variable, pre-pregnancy BMI was the only statistically significant parameter with a difference between the groups (p?=?0.044). No statistical difference was found between the groups in the rate of pre-pregnancy counselling (60% vs. 67%), glycaemic control prior to pregnancy (Hba1c 7.5 vs. 7.1%), the prevalence of patients achieving desired level of glycaemic control (44% vs. 42%), weight gain during pregnancy (12.4 vs. 10.6?kg), duration of DM (18.0 vs. 19.7 years) and proportion of patients treated with angiotensin converting enzyme inhibitors prior to pregnancy (26 vs. 33%).

Conclusion.?Overweight is associated with poor pregnancy outcome in patients with Type-1 DM and different degrees of nephropathy.     

儿童1型糖尿病动态血糖监测的临床意义

目的应用动态血糖监测系统(CGMS)观察1型糖尿病患儿血糖控制情况，寻找评价和改善血糖控制的方法。 方法收集复旦大学附属儿科医院2003年10月至2004年6月内分泌科门诊随访的儿童1型糖尿病患者28例，男16例，女12例，年龄(131±45)岁，病程(55±34)年，其中21例采用每天多次胰岛素注射(MDI),另7例使用胰岛素泵连续胰岛素输注(CSII)治疗。动态监测血糖3d，同时指尖血糖监测≥4次/d。 结果(1)研究对象体重指数(BMI)为(194±30)kg/m2,糖化血红蛋白(HbA1c)为(84±16)%。CSII组HbA1c(82±10)%,MDI组HbA1c(85±18)%,差异有显著性意义(P<005);(2)CGMS发现22例77次餐后2h高血糖，CSII组4例(571%),每例出现1次，MDI组18例(857%),每例出现(41±25)次,差异显著(P<001)；(3)CGMS发现17例79次低血糖，持续时间(766±928)min,而指尖血糖监测仅发现19次低血糖;白天低血糖持续时间(415±391)min，夜间(1124±1171)min，夜间低血糖持续时间显著长于白天(P<001)。(4)HbA1c≤8%组餐后高血糖发生率低于HbA1c>8%组(P<005)，而低血糖的发生率显著升高(P<001)。 结论1型糖尿病患儿多数存在低血糖和餐后高血糖；动态血糖监测系统是发现血糖异常波动的有效工具。动态血糖监测对指导1型糖尿病治疗，调整胰岛素剂量，从而改善血糖控制有着重要的临床意义。     

Evaluation of relationship between HbA1c levels and ovarian reserve in patients with type 1 diabetes mellitus

Abstract

In organ or non-organ-specific autoimmune disorders, human ovary is usually the target of the autoimmune attack. We aimed to demonstrate the correlation between ovarian reserve and DM1, based on the view that women with type-1 diabetes mellitus (DM1) will have lower AMH levels secondary to poor glycemic control and autoimmune attacks. Ovarian functions of 42 patients diagnosed with DM1 who use insulin and 65 healthy volunteers were analyzed. Basal hormone and AMH levels were measured during the follicular phase. Fasting and postprandial blood glucose concentrations, HbA1c and C-peptide levels were evaluated. The mean antral follicle count (AFC) was significantly lower in DM1 patients than in healthy controls (p?=?.001). The AMH levels were lower in women with DM1 than in the controls (p?=?.001). The HbA1c values of DM1 patients, who formed the study group, was significantly higher than the control group. Ovarian reserve that is evaluated with serum AMH level is affected by poor glycemic control in type 1 diabetes. Due to the time of the autoimmune damage in the ovaries and the observable effects of this damage, more comprehensive and longer-term studies are needed to be conducted for the follow-up of reproductive abnormalities.     

Obstetric interventions for women with type 1 or type 2 diabetes

Objective

To determine whether differences exist in the rates of obstetric intervention between women with type 1 diabetes and those with type 2 diabetes, and whether there has been any change in cesarean rates over time, paralleling that seen in the general obstetric population.

Methods

Data were examined from a prospectively collected series on the outcomes of 1030 deliveries (382 by women with type 1 diabetes, 648 by women with type 2 diabetes) from 1988 to 2008.

Results

There was a secular trend to increasing maternal age (type 1, P < 0.003; type 2, P < 0.03). Intervention rates (induction of labor or elective cesarean) did not differ between type 1 (88%) and type 2 (85%) diabetes. The overall cesarean rate was 52%–55% with no secular trend. Poorer glycemic control in early pregnancy and primiparity were associated with primary cesarean in both groups. In women with type 1 diabetes, greater maternal obesity and retinopathy were also associated with primary cesarean.

Conclusion

Intervention rates are high in pregnancies among women with type 1 diabetes and those with type 2 diabetes but they have not changed significantly. Secular trends toward increasing maternal age and obesity suggest that intervention rates are unlikely to decrease in the near future.     

Menarcheal age of type 1 diabetic Bengali Indian females

Abstract

Background: It has been observed that menstrual characteristics are generally influenced by lifestyle, socio-cultural and biological factors.

Aim: The present study examines: (a) variation in menstrual characteristics between Type1 Diabetic females of rural and urban adolescents, i.e. the resident status; and (b) whether these characteristics can be predicted from various socio-economic, stress variables related to place of residence.

Subjects and methods: The sample of the present study constituted 103T1DM females from West Bengal, a State of India. These girls belong to a Bengali-speaking ethnic group. Data on socio-economic variables and menstrual characteristics were collected using pretested questionnaires.

Results: Menstrual irregularity was common in our study participants, with age of menarche, but was not associated with current BMI, physical activity or insulin dose.

Conclusions: Our study displays that age at menarche is delayed in young women with T1DM compared to the concurrent overall mean age at menarche in the West Bengal population.     

The prevalence of congenital malformations is still higher in pregnant women with pregestational diabetes despite near-normal HbA1c: a literature review

Aims/hypothesis: We assessed the association between congenital malformations and maternal hyperglycemia in pregnant women with pregestational (type 1 or type 2) diabetes and investigated if the rate of congenital malformations was similar in women with near-normal glycemic control compared to the background population. We also assessed the association between congenital malformations and maternal hyperglycemia in pregnant women with pregestational diabetes with special focus on women with near-normal HbA1c in early pregnancy.

Materials and methods: This is a literature review based on an electronic literature search of the databases PubMed, Cochrane, Embase and Web of Science conducted in July 2017 using the search terms diabetes, pregnancy, HbA1c or glycemic control and congenital anomaly or congenital anomaly. We included original papers in English published after 1997 with data on congenital malformations and HbA1c in at least 250 women with pregestational diabetes.

Results: Nine papers with in total 6225 women with type 1 diabetes and 2334 women with type 2 diabetes were included. The prevalence of congenital malformations was 6.4% in women with type 1 diabetes and 4.3% in women with type 2 diabetes and for the combined group of women with pregestational diabetes, the relative risk compared to the background population was 3.2. In women with HbA1c?Conclusions: In pregnant women with pregestational diabetes the prevalence of congenital abnormalities was threefold higher in women with pregestational diabetes compared to the background population. However, HbA1c below 53?mmol/mol (7.0%) in early pregnancy was also associated with a two times increased risk of congenital malformations compared to the background population.     

Juggling type 1 diabetes and pregnancy in rural Australia

Objective

to explore the experiences of women with type 1 diabetes, living in rural Australia, while preparing for pregnancy and childbirth. Additionally, we aimed to describe the women's engagement with, and expectations of, health-care providers during this period, and subsequently highlight potential service and informational gaps.

Design

qualitative research using a collective case-study design; seven women with type 1 diabetes who had given birth within the previous 12 months participated in in-depth interviews about their experiences of pregnancy and birth. Data were analysed thematically.

Setting

The experience of type 1 diabetes, preconception preparation and pregnancy among rural Australian women was explored, including interactions with health professionals.

Participants

seven women aged between 26 and 35 years agreed to be interviewed. The woman had one or two children and had given birth within the past 12 months.

Findings

rigid narrow control of blood glucose levels before conception and during pregnancy created unfamiliar body responses for women, with hypoglycaemic symptoms disappearing or changing. For example, some women mentioned developing tunnel vision or numbness and tingling around their lips and tongue as different symptoms of hypoglycaemia. Women needed information and support to differentiate between what might be normal or abnormal bodily processes associated with pregnancy, diabetes, or both. The women's preparation for conception and pregnancy was reliant on the level of available expertise and advice. Participants’ experiences were coloured by their limited access and interactions with expert health professionals.

Conclusion

women with type 1 diabetes experienced significant hardship during their pregnancy, including a higher incidence of hypoglycaemic episodes, a loss of hypoglycaemic symptom recognition and weight gain. These difficulties were compounded by a scarcity of available information to support the management of their pregnancy and a lack of availability of experienced health professionals.

Implications for practice

national and international consensus guidelines emphasise the importance of preconception and pregnancy care for women with type 1 diabetes. Close clinical supervision and the development of closer co-operation and partnership between the women and health-care providers before conception and during pregnancy may improve outcomes for these women and their babies. Building confidence in professional care requires increased access to specialist services, increased levels of demonstrated knowledge and expertise and better general community access to information about preparation for pregnancy and birth among women who have type 1 diabetes.     

Prediction of preeclampsia in type 1 diabetes in early pregnancy by clinical predictors: a systematic review

Purpose: The purpose of this study is to evaluate the prevalence and possible clinical predictors of preeclampsia present in early pregnancy among women with type 1 diabetes.

Methods: A systematic search of PubMed was conducted in April 2017. Inclusion criteria were largely unselected cohort, including at least 100 women with type 1 diabetes, dealing with either the prevalence of preeclampsia or possible clinical predictors of preeclampsia identified in early pregnancy.

Results: Based on 11,518 pregnancies in 11 articles, the prevalence of preeclampsia in women with type 1 diabetes was 17%, five to six times more than in the background population. In early pregnancy, the following clinical predictors were associated with increased prevalence of preeclampsia: diabetic nephropathy (OR 3.7–23.5), microalbuminuria (OR 3.8–11.7), diabetic retinopathy (OR 1.9–2.9) and pre-existing hypertension (OR 3.8–17.1) as well as high blood pressure within the normotensive range. HbA1C, body mass index and nulliparity were positively associated with preeclampsia, but not consistently.

Conclusion: The prevalence of preeclampsia in women with type 1 diabetes was 17%. In early pregnancy pre-existing hypertension and high blood pressure within the normotensive range as well as presence of microangiopathy were predictors of preeclampsia. Poor glycaemic control, obesity and nulliparity probably also contribute to the increased risk.     

IGF-1 is associated with fetal growth and preterm delivery in type 1 diabetic pregnancy

Aim: No data on IGF-1 and either preterm or preeclampsia have been reported so far in diabetic pregnancies. We evaluated consecutive measurements of IGF-1 for preeclampsia, preterm delivery and birth weight in type 1 diabetic pregnancy.

Setting: In an outpatient university clinic, 97 pregnant women were consecutively recruited for evaluation of indicators for deterioration of diabetes status and adverse perinatal outcome. At every visit, a blood sample for measurement of IGF-1 was drawn.

Results: IGF-1 levels from week 14 to 32 was consistently lower in women who delivered preterm compared with women whose delivered after gestational week 36; the increase in 2nd and 3rd trimester was steeper in those delivering at term than in women delivering preterm (p?=?0.032). IGF-1 in preeclampsia did not show the same relation in diabetic women (p?=?0.74). The lowest tertile of birth weight ratio (0.8–1.2) was associated with lower IGF-1 from week 14 to 32 (p?=?0.047, adjusted for preterm delivery and preeclampsia).

Conclusion: We found low IGF-1 levels associated with preterm delivery and low birth weight.     

Type 1 diabetes mellitus associated or not with primary hypothyroidism and women’s fertility

Abstract

The aim of this study is to evaluate the prevalence of infertility and other reproductive parameters in women with type 1 diabetes mellitus (DM1) with and without primary hypothyroidism (PH). This is a cross-sectional study conducted at Division of Endocrinology. We evaluated 110 female, aged over 18 years, 79 had DM1 and 31 had DM1 plus PH. They were interviewed to obtain data on their gynecological and obstetric history; medical charts were reviewed to determine the characteristics of the diseases and to assess clinical/laboratory data. Infertility was defined as 12 months of unprotected sexual intercourse without conception. We used the chi-square and Mann–Whitney’s tests, and logistic regression analysis. The prevalence of infertility in the total sample was 24.5%, no differences were found between groups regarding obstetric outcomes and gynecologic variables. Factors associated with infertility were microvascular complication (OR: 11.36; 95% CI: 2.488–52.632; p?=?.029), polycystic ovary syndrome (OR: 9.80; 95% CI: 2.247–43.478; p?=?.016), PH (OR: 3.38; 95% CI: 1.078–10.638; p?=?.047), and older age at onset of DM1 (OR: 1.12; 95% CI: 1.029–1.215; p?=?.019). The presence of PH in women with DM1 was a predictive factor for infertility. Women with DM1 showed poorer reproductive outcomes compared to the general population.     

Maternal and perinatal outcomes in pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion and real time continuous glucose monitoring in two specialized centers in Medellin,Colombia

Objective: We assessed maternal and perinatal outcomes in pregnant women with type 1 diabetes, treated with continuous subcutaneous insulin infusion and real time continuous glucose monitoring.

Methods: This is a retrospective study, analyzing the basal characteristics, glycemic control, maternal and perinatal outcomes of pregnant women with type 1 diabetes, who were on an insulin pump with continuous glucose monitoring between 2011 and 2015.

Results: Fourteen patients were included. The median age was 33 and disease duration 12 years. Indications for therapy were mainly poor glycemic control and severe hypoglycemia. The median A1c decrease was 1.02% between the first and third trimester. Pregnancies were associated with complications: 7.1% of the patients had diabetic ketoacidosis, 7.1% had an abortion, 28.5% gestational hypertension and 12.2% preeclampsia. The median gestational age at birth was 37 weeks and four days; the frequency of preterm birth was 7.1% and macrosomia 21.4%. There were no congenital malformations or perinatal death.

Conclusions: Baseline characteristics and results of patients in this study were similar to those reported in the previous literature. Continuous subcutaneous insulin infusion with continuous glucose monitoring is an alternative treatment option for pregnant women with type 1 diabetes before or during pregnancy.     

HbA1c during pregnancy: its relationship to meal related glycaemia and neonatal birth weight in patients with diabetes

OBJECTIVE: Although home blood glucose (HBG) profiles correlate closely with HbA1c, the strength of the relationship during pregnancy is unclear due to physiological changes which can induce subnormal HbA1c levels. We therefore aimed to establish the strength of the association between mean HBG profiles and HbA1c in diabetic pregnancies and whether HbA1c levels and glycaemic variability affects neonatal birth weight (NBW). STUDY DESIGN: 7-point glycaemic profiles performed throughout pregnancy were obtained retrospectively in 94 consecutive patients attending the diabetes antenatal clinic and compared to the corresponding mean HbA1c levels. RESULTS: There was a significant linear correlation between mean HBG and HbA1c (HbA1c=0.5HBG+3.1, r=0.71, p<0.0001). Multiple regression analysis demonstrated that both pre- and post-prandial HBG levels correlated significantly and independently with HbA1c, correlation coefficients (r) were 0.63 and 0.65, respectively both p<0.0001. Significant correlations were also observed in patients with gestational diabetes (n=67, mean HbA1c=6.11, r=0.67; p<0.0001) and type 1 diabetes (n=18, mean HbA1c=6.75, r=0.64; p=0.004). All meal related HBG measurements showed similar significant correlations with HbA1c (r values pre- and post-breakfast, pre- and post-lunch, pre- and post-tea and pre-bed are 0.56, 0.55, 0.59, 0.55, 0.56, 0.59, 0.51, respectively p<0.0001 for all time points). Post hoc analysis showed that NBW increased with higher levels of HbA1c; NBW (centiles)+/-S.D. for HbA1c <6.5% versus >6.5% was 78.9%+/-29.2 versus 90.2%+/-18.6, p=0.02. CONCLUSION: Mean HbA1c levels are closely correlated to all meal related glucose measurements during pregnancy. It is therefore a reliable indicator of overall glycaemic control among patients with diabetes during pregnancy.     

Benefits, risks, costs, and patient satisfaction associated with insulin pump therapy for the pregnancy complicated by type 1 diabetes mellitus

OBJECTIVE: Glycemic control, perinatal outcome, and health care costs were evaluated among women with type 1 diabetes mellitus who began insulin pump therapy during pregnancy (group 1, n = 24), were treated with multiple insulin injections (group 2, n = 24), or were already using an insulin pump before pregnancy (group 3, n = 12). Patient satisfaction and continuation of pump therapy post partum were assessed. STUDY DESIGN: A retrospective review of maternal and neonatal medical records was performed, and a questionnaire was sent to patients after delivery. Patients in groups 1 and 2 were matched for age, age at onset and duration of diabetes mellitus, White class, and date of delivery. RESULTS: No differences in glycosylated hemoglobin A levels were observed among groups 1, 2 or 3 in the first, second, or third trimester. Patients in group 1 started pump therapy at a mean of 16.8 weeks' gestation, and 17 (70.8%) began therapy as outpatients. No deterioration in glycemic control was noted during the 2- to 4-week period after the start of pump treatment. Among the women in group 1 eight had at least one episode of severe hypoglycemia before starting pump therapy, but only one had such an episode after this treatment was begun. Two episodes of ketoacidosis occurred in group 1, and no episodes occurred in groups 2 and 3. No significant differences in perinatal outcomes or health care costs were observed among groups 1, 2, and 3. After delivery 94. 7% of the women in group 1 continued to use the pump because it provided better glycemic control and a more flexible lifestyle. Postpartum glycosylated hemoglobin A values were 7.2% in group 1 and 9.1% in group 2, a significant difference. CONCLUSIONS: Insulin pump therapy was initiated during pregnancy without a deterioration of glycemic control and was associated with maternal and perinatal outcomes and health care costs comparable to those among women who were already using the pump before pregnancy or who received multiple-dose insulin therapy. Women who began pump therapy in pregnancy were highly likely to continue pump use after delivery and preferred the flexible lifestyle that this treatment allowed.     

Risk factors,pregnancy complications,and prevention of hypertensive disorders in women with pregravid diabetes mellitus

Objective: To review the rate, risk factors, and potential prevention of preeclampsia in women with pregravid diabetes mellitus.

Methods: Detailed review of recent English literature describing pregnancy outcome in women with pregravid insulin-dependent diabetes mellitus (Type 1 diabetes). The primary focus of the review is risk factors for preeclampsia and potential methods suggested for prevention of preeclampsia. In addition, pitfalls in diagnosis of preeclampsia will be emphasized.

Results: The reported rate of preeclampsia ranged from 9% to 66%. This rate increased with increased severity of diabetes by White's classification, with the highest rate reported in women with pregravid diabetic nephropathy. Risk factors identified for preeclampsia were nulliparity, chronic hypertension, microalbuminuria prior to pregnancy, nephropathy, and poor glycemic control early in pregnancy. There is lack of agreement among reports in the literature concerning criteria used to diagnose preeclampsia. There are two randomized trials that included women with Type 1 diabetes who were randomized to receive either low-dose aspirin or placebo. There was no reduction in the rate of preeclampsia with low-dose aspirin in either trial.

Conclusions: In women with pregravid Type I diabetes, the rates of preeclampsia and adverse neonatal outcome increase with increased severity of diabetes. Low-dose aspirin does not reduce rate of preeclampsia in such women. Further studies should address the role of good glycemic control prior to 20 weeks gestation and prevention of microalbuminuria.