Pre-existing (type 1 and type 2) diabetes in pregnancy

The prevalence rates of both type 1 and type 2 diabetes mellitus are increasing in the UK. These rates are resulting in a higher number of women with pregnancy complicated by pre-existing diabetes being seen in maternity clinics. Specifically, there is a continuing marked increase in the number of women with type 2 diabetes and pregnancy. Confidential Enquiry into Maternal and Child Health (CEMACH) has recently reported findings from a large study of pregnancy outcome in women with type 1 and type 2 diabetes. We review the current understanding of diabetes in pregnancy, and discuss the CEMACH findings and current and future developments in the delivery of pre-conception and diabetes care in established pregnancy in the UK.     

Gestational diabetes: screening,diagnosis, treatment and management

Gestational diabetes (GDM) is a common medical condition in pregnancy, and is associated with a range of short and long term maternal and infant complications including pre-eclampsia, pre-term birth, caesarean section, stillbirth, macrosomia and large-for-gestational age, neonatal hypoglycaemia, and increased risk of later type 2 diabetes in both mother and offspring. The incidence of complications can be reduced and pregnancy outcomes for these women are generally good with effective management of hyperglycaemia using regular monitoring of blood glucose, antenatal care with a multidisciplinary team, diet and lifestyle intervention, and pharmacotherapy. Risk of recurrence in future pregnancies, and of later development of type 2 diabetes is high in women with GDM. Attention should be given to screening and reducing risk in women who have experienced GDM, with encouragement of breastfeeding, diet and lifestyle intervention, weight management, and possibly metformin.     

Which contraceptive methods are recommended for young women with type 1 diabetes mellitus? A survey among gynaecologists in Greece.

BACKGROUND: Type 1 diabetes mellitus is common in Europeans. Optimal glucometabolic control at conception and during early pregnancy is necessary to reduce the risk of early miscarriage and congenital malformations. Safe and effective contraceptive methods are essential for these women in order to have a "planned pregnancy" under optimal conditions. AIM: To find out which recommendations Greek gynaecologists give to young patients with type 1 diabetes mellitus with respect to contraception. To regard the experience of Greek gynaecologists in counselling with women. To compare the Greek gynaecologists with German gynaecologists in a previously published similar survey. SUBJECTS AND METHODS: A structured questionnaire containing questions about attitude, health care and contraception in young women with type 1 diabetes was given to 400 Greek gynaecologists working in Athens. RESULTS: Only 70 (17.5%) of the Greek gynaecologists returned the questionnaire. Condoms were the preferred recommendation as contraceptive method for young women with diabetes mellitus type 1 in 64%. About 57% of the gynaecologists recommended this type of contraception as first line contraceptives for young women with diabetes type 1 who smoke. The two most important criteria for selection of a contraceptive method for Greek gynaecologists were the safety and the diabetes specific problems. The Greek gynaecologists had only limited experience in regard to counselling and treating young and adolescent women with type 1 diabetes. CONCLUSION: There was no consensus with respect to contraception among Greek gynaecologists. This is similar to our previous findings in a survey involving German gynaecologists. Practical experience in counselling and treating adolescent and young women with type 1 diabetes was limited among the gynaecologists who participated in this study. Working out proper recommendations for contraception crucial for optimal medical care for type 1 diabetic women in Europe.     

Physiopathology and nutritional care of patients with gestational diabetes

Maternal risks include the development of diabetes after pregnancy, as well as having an infant with macrosomia, with elevated risk of developing obesity and diabetes in childhood. The main goal of treatment is to maintain an adequate glycemic control during pregnancy and guarantee the recommended weight gain. The first treatment strategy is diet therapy, however, some women need insulin therapy to achieve adequate glycemic control. The risk of diabetic fetopathy decreases when maintaining postprandial glycemic levels within normal ranges. These levels are directly associated with the amount and type of carbohydrates consumed during meals. So, nutrition therapy should be an integral part of gestational diabetes treatment. Nutrition therapy includes a complete nutrition assessment, an individual food plan that meets energy and protein requirements for pregnancy (in obese women never lesser than 1,700 kcal/day), in which lipids and carbohydrates may provide lesser than 40 and between 40 and 45% of total energy intake. Education about food groups that provide carbohydrates, portion sizes and how to achieve an equal carbohydrate distribution throughout the day should be provided. Orientation about eating healthy fats and increasing the consumption of high-fiber foods should also be included. This approach requires that treatment of women with gestational diabetes should be provided by a multidisciplinary team, including nutrition specialists.     

50例妊娠合并糖尿病孕妇的妊娠期管理分析

目的 :探讨妊娠合并糖尿病孕妇的妊娠期管理方法。方法 :将 5 0例妊娠合并糖尿病孕妇与 4 8例正常孕妇比较。结果 :5 0例妊娠期糖尿病孕妇中有 38例 ( 76 % )经饮食疗法后血糖控制效果良好 ,另 12例需饮食疗法加胰岛素治疗方能将血糖控制在正常范围内。经临床治疗后 ,5 0例妊娠合并糖尿病的孕妇 ,除早产发病率高于非糖尿病组孕妇外(P <0 0 5 ) ,妊高征、感染、产后出血、羊水过多、羊水过少、胎儿窘迫、巨大儿、胎儿生长受限 (FGR)、新生儿窒息、新生儿高胆红素血症等发病率与非糖尿病组孕妇无区别。结论 :加强妊娠合并糖尿病孕妇的妊娠期管理 ,用饮食疗法或胰岛素治疗控制血糖 ,适时终止妊娠 ,可有效降低母婴并发症的发生     

Women's perceptions of being pregnant and having pregestational diabetes

Objectiveto explore the experiences of White British and South East Asian women with type 1 and type 2 diabetes, and the perceived impact of diabetes on their reproductive health.Designa hermeneutic phenomenological approach was used to explore the perceptions of women with diabetes from two different cultural backgrounds with varied reproductive health experiences. Focus groups and one-to-one interviews were used to elicit women's experiences. An interpretive analytical approach was conducted by two researchers.Settingobstetric and diabetes clinics in three hospital sites in the North West of England.Participantsa purposive sample of 22 women with type 1 or type 2 diabetes of different parity and ethnicity.Findingsthe main themes were relinquishing personal control, pregnancy overshadowed by diabetes and haphazard preconception care.Key conclusionsstrategies should be developed to ensure that whilst safety is maintained, the pregnancy focus is not lost. Women should be supported to optimise their experience as well as clinical outcomes. The convergence of professional roles needs consideration; individual members of multidisciplinary diabetes teams should provide a unique and complementary contribution to care. Preconception care needs to be accessible and responsive to women; this should include recognition of socio-cultural differences.     

Pre-existing type I and type II diabetes in pregnancy

Diabetes mellitus is a long term chronic condition. The prevalence of diabetes in pregnancy is 2–5% in the UK of both gestational diabetes and pre-existing diabetes. The pregnancy outcomes for pre-existing type I and type II diabetic women are worse than for non-diabetic mothers. There is a higher incidence of stillbirth, macrosomia and congenital malformations. Pre-pregnancy counselling is essential to prepare for pregnancy, to tighten glycaemic control and review medication prior to pregnancy. Multi-disciplinary care is required throughout the antenatal period, to optimise blood glucose monitoring and control. Screening for diabetic complications such as nephropathy and retinopathy is necessary at every trimester to detect progression of disease. The timing, mode and management of delivery with a plan to maintain glycaemic control during this time should be discussed by 36 weeks. After completion of 38 weeks' gestation, induction of labour may be considered. This review will discuss the management of pre-existing type I and type II diabetic women from the preconception period to the postpartum period.     

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.     

Pregnancy planning in women with pregestational diabetes

Objectives.?Women with pregestational diabetes are advised to plan their pregnancies to optimize glycemia and reduce fetal complications. We evaluated the adequacy of pregnancy planning effort and medical planning in pregnant women with type 1 and type 2 diabetes.

Methods.?This retrospective cohort study surveyed pregnant women with pregestational diabetes mellitus between 2006 and 2008 in Ontario, Canada. We evaluated three measures of pregnancy planning: pregnancy planning effort, medical planning based on prepregnancy glycemic control, and folic acid use. We compared women with type 1 and type 2 diabetes and explored predictors of pregnancy planning.

Results.?Of the 163 women studied (89 type 1, 74 type 2 diabetes), 47% reported high pregnancy planning effort, 58% reported attempts to optimize glycemic control, and 56% took folic acid before pregnancy. Of those who reported high pregnancy planning, 20% did not medically plan their pregnancies. Rates were similar between women with type 1 and type 2 diabetes. The most important predictor of pregnancy planning was having discussed plans with their physician.

Conclusions.?Our findings suggest that pregnancy planning is suboptimal in women with both type 1 and type 2 diabetes, highlighting a need to improve preconception counseling for all women with pregestational diabetes.     

Seizures in pregnancy: Epilepsy,eclampsia, and stroke

Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.     

Perinatal HIV transmission and pregnancy outcomes in indigenous women in Western Australia

BACKGROUND: Implementation of obstetric and neonatal interventions has reduced mother to child transmission of HIV. Health outcomes for Aboriginal people are often worse than for non-Aboriginal people; was this the case for HIV infection in pregnancy? AIMS: To compare the management and outcomes of pregnancy in Aboriginal and non-Aboriginal HIV-positive women in Western Australia (WA). METHODS: A retrospective study of all pregnancies delivered in WA to HIV-infected women from 1991 until 2005. Managed pregnancies were compared in Aboriginal and non-Aboriginal women. Outcome measures were HIV status of the babies, birthweight, rates of caesarean delivery and perinatal mortality. RESULTS: Fifty-six pregnancies occurred in 41 HIV-infected women resulting in 54 live births. Of the 41 women, 16 (39%) were Aboriginal. In regard to birthweight, perinatal mortality, rates of caesarean section and rates of HIV perinatal transmission, there was no significant difference between babies born to Aboriginal and those born to non-Aboriginal mothers. In contrast, of the eight pregnancies, with no contact with the multidisciplinary team, five babies (63%) were infected with HIV (2% vs 63%P = 0.001). There was no case of perinatal HIV infection in 22 pregnancies of the Aboriginal women that received care through the multidisciplinary team; perinatally acquired HIV occurred in the first pregnancy of one of these women before she was aware of her status when she was not managed by the team. CONCLUSIONS: Similar outcomes can be achieved in both HIV-positive Aboriginal and non-Aboriginal women, through intensive, culturally appropriate, multidisciplinary care and without elective caesarean delivery.     

Women's Perceptions of Outcomes of Prenatal Case Management

Background: Comprehensive case management is a multidisciplinary, community‐based service often available to Medicaid‐eligible women. The purpose of the study was to identify the variety of maternal outcomes, other than birth outcomes, attributable to comprehensive prenatal case management. Method: This qualitative study used a social ecological approach. Twenty‐four women were interviewed about the outcomes they experienced as a result of comprehensive prenatal case management. Ethnographic content analysis was used for data reduction. The participants' mean age was 25.4 (SD = 8.4) years, with an average parity of 1.9 (SD = 1.1). Fifteen participants (68%) had a 12th grade education or less. Ethnic minorities were included in the sample. Eleven participants (47%) worked at least part‐time, although 23 (98%) were receiving Medicaid and 21 (88%) were receiving the Women, Infants, and Children's (WIC) supplementary nutrition program. Results: The women attributed improvements of various types to the actions of the case manager, specifically in the areas of emotional well‐being, learning, lifestyle behaviors, financial situation, services utilization, and maternal and infant physical health. Conclusion: Case management appeared to have immediate effects on the women, as well as intermediate effects, such as changes in lifestyle behaviors and services utilization. The women attributed those changes to having a healthy pregnancy.     

Postpartum metabolism and autoantibody markers in women with gestational diabetes mellitus diagnosed in early pregnancy

OBJECTIVE: Our purpose was to study postpartum metabolism and autoantibody markers of type 1 diabetes mellitus in women with gestational diabetes mellitus diagnosed in early pregnancy. STUDY DESIGN: Thirty women with gestational diabetes diagnosed in early pregnancy were compared with 72 women who had gestational diabetes diagnosed in late pregnancy. Glucose tolerance, parameters of carbohydrate and lipid metabolism, and antibodies to glutamic acid decarboxylase and to islet cells were measured. RESULTS: The percentages of overt diabetes and abnormal glucose tolerance were significantly higher in the early-pregnancy group (26.7% vs 1.4%; P =.0002; and 40% vs 5.56%; P <.0001; respectively). Only 1 woman had positive test results for antibodies to the islet cells. The rate of positive test results for antibodies to glutamic acid decarboxylase was similar in both groups (13.7% vs 9.3%). CONCLUSIONS: Women with early gestational diabetes have an increased risk of postpartum diabetes mellitus, whereas those with late-onset gestational diabetes have a minimal risk. In women predisposed to type 1 diabetes, gestational diabetes develops either early or late in pregnancy.     

Maternal Hypertension and Spontaneous Preterm Births Among Black Women

Objective: To examine effects of maternal hypertension on spontaneous preterm birth (birth at less than 37 weeks’ gestation) among black women.Methods: Using hospital discharge summary records from the National Hospital Discharge Survey between 1988 and 1993, we conducted a case-control study to assess the risk of spontaneous preterm birth among black women with chronic hypertension preceding pregnancy and pregnancy-induced hypertension. Logistic regression was used to derive odds ratios (ORs) and 95% confidence intervals (CIs).Results: Preterm births were almost two times more likely for women with pregnancy-induced hypertension (OR = 1.8; 95% CI, 1.5, 2.2), more than 1.5 times more likely for women with chronic hypertension preceding pregnancy (OR = 1.6; 95% CI, 1.3, 2.1), and more than four times more likely for women with pregnancy-aggravated hypertension (OR = 4.4; 95% CI, 2.9, 6.7) compared with normotensive women. Preterm births also were associated significantly with antepartum hemorrhage, poor fetal growth, marital status, and source of payment. The odds of preterm birth by maternal hypertension were increased among women with chronic hypertension and genitourinary infection, whereas the odds of preterm birth were reduced among women with pregnancy-induced hypertension and genitourinary infection.Conclusion: These findings are important in demonstrating the relation between type of hypertension in pregnancy and preterm birth. The relationships between maternal hypertension and preterm birth need to be further investigated to provide some guidelines in the management of hypertension in pregnancy and assessment of prenatal care compliance for black women, particularly when genitourinary infection is present.     

Diabetes: lessons for midwives

This study is larger than any other in describing pregnancy outcomes for women with pre-gestational diabetes. From the report, the three main messages for midwives are: Women with type 2 diabetes have a risk of poor outcome similar to those with type 1 diabetes. The same support and management of women with type 1 diabetes should be applied to women with type 2 diabetes pre-conceptionally and throughout the pregnancy and neonatal period. Pre-pregnancy care and advice should be made more flexible and advertised well in a variety of settings where diabetic women of childbearing age are most likely to see it. Women with diabetes should be encouraged and supported to breastfeed their babies from birth by giving them an understanding of the general and specific benefits this will provide.     

The role of continuous glucose monitoring in clinical decision-making in diabetes in pregnancy

BACKGROUND: The continuous glucose monitoring system (CGMS) is a novel tool to assess 24-h glucose fluctuations. In pregnancies complicated by diabetes, where excellent glucose control is desired to improve maternal and fetal outcomes, CGMS may have a role in fine-tuning management. AIMS: To assess the usefulness of CGMS in pregnant women with diabetes for medical decision-making and to evaluate patient tolerability and perception of usefulness. METHODS: Pregnant women with diabetes at the Werribee Mercy Hospital were offered CGMS in the setting of their standard diabetes care. Treating clinicians were asked if the CGMS altered management decisions from those based on conventional glucose monitoring. The accuracy of the CGMS was assessed by comparison with the patients' finger-prick glucose readings. Patients completed a feedback questionnaire after having the CGMS and viewing their results. RESULTS: CGMS traces (n = 68) were obtained in 55 pregnant women - 37 with gestational diabetes, ten with type 2 and eight with type 1 diabetes. Forty-two of 68 (62%) traces were assessed as providing additional information which altered clinical management decisions. This included showing undetected postprandial hyperglycaemia and overnight hypoglycaemia. Subject feedback was generally positive, with 37 of 48 (77%) respondents reporting that the benefits of the CGMS outweighed the inconvenience. CONCLUSION: CGMS is a well-tolerated clinically useful tool in the management of gestational diabetes and pre-existing diabetes in pregnancy.     

Gynaecological malignancies in pregnancy

PURPOSE OF REVIEW: To review the management of gynaecological cancers occurring in association with pregnancy. To consider the impact of the cancer on the pregnancy, and the impact of the pregnancy on the cancer. RECENT FINDINGS: The management of gynaecological cancers in pregnancy remains, fortunately, a rare problem for the gynaecological oncology team. This inevitably means that many management decisions will be informed by relatively small case series and case reports. There have been interesting reports where pregnancy has been prolonged to achieve fetal viability in both cervix and ovary cancer in pregnancy, and these are discussed below. SUMMARY: Any cancer in pregnancy is a catastrophic event for the woman and her partner, and poses great challenges for the multidisciplinary team responsible for her care. Gynaecological cancers in pregnancy are even more stressful as the woman will naturally worry about the survival of her baby, and the implications for her future fertility. Fortunately the outcome for most women and their babies is favourable.     

Pregestational diabetes: insulin requirements throughout pregnancy

The management of pregestational diabetes requires tight metabolic control to reduce maternal and perinatal morbidity and mortality. It has been suggested that type I diabetes is a disorder characterized by insulin deficiency and type II diabetes is characterized by insulin resistance; however, it may be hypothesized that a difference in insulin requirements should emerge throughout pregnancy to reflect the dissimilarities in these two metabolic disturbances. The current investigation of 103 women with pregestational diabetes used a novel approach (reflectance meters with onboard memories) to uncover the actual insulin dosages required to reach and maintain optimum metabolic control throughout pregnancy. It was found that both type I and type II diabetes appear to have a triphasic insulin pattern, with the patient having type II diabetes requiring significantly higher doses of insulin during each trimester. This seems to suggest that the hormonal changes in pregnancy may have a similar effect on both type I and type II diabetes but to a different degree. Thus this should be considered in the treatment of pregestational diabetes and in the development of an algorithm for diabetes management.     

Postnatal testing for diabetes in Australian women following gestational diabetes mellitus

Background:  Postnatal blood glucose testing is recommended for reclassification of glucose tolerance following a pregnancy affected by gestational diabetes mellitus (GDM); however, there are limited data on the postnatal follow-up sought by Australian women.
Aims:  To describe postnatal diabetes testing patterns in Australian women following a pregnancy affected by GDM and identify factors associated with return for follow-up testing in accordance with the Australasian Diabetes in Pregnancy Society (ADIPS) guidelines.
Methods:  A cross-sectional self-administered survey of 1372 women diagnosed with GDM between 2003 and 2005, sampled from the National Diabetes Services Scheme database.
Results:  Postnatal diabetes testing was reported by 73.2% of survey respondents with 27.4% returning for an oral glucose test tolerance at six to eight weeks post-GDM pregnancy. Using logistic regression analysis, factors associated with appropriate postnatal testing were receiving individualised risk reduction advice (odds ratio (OR) 1.41 (1.08,1.84)) or written information (OR 1.35 (1.03,1.76)) and in two-way interactions, being under the care of an endocrinologist and not tertiary educated (OR 2.09 (1.49,2.93)) as well as seeing an obstetrician and diabetes educator during pregnancy (OR 1.72 (1.19,2.48)). Every five years increase in age reduced the likelihood of a woman returning for testing by 17%.
Conclusions:  Specialist diabetes care in non-tertiary educated women, or a team approach to management with diabetes education and obstetric care may act to reinforce the need for postnatal diabetes testing in accordance with the ADIPS guidelines. Individualised follow up from a health professional and provision of written information following a GDM pregnancy may also encourage return for postnatal testing in this high-risk group.     

Metabolic syndrome in normal and complicated pregnancies

OBJECTIVE: To evaluate the prevalence of metabolic syndrome and its components in normal and complicated pregnancies. STUDY DESIGN: Setting: university hospital, tertiary referral centre. Subjects: 90 pregnant women in four groups: 20 women with preeclampsia, 20 women with gestational hypertension, 30 women with late-onset gestational diabetes and 20 healthy pregnant women as a control group. Intervention: peripheral insulin resistance was measured by using the insulin tolerance test. Glucose, triglycerides, high-density lipoprotein cholesterol, blood pressure and body mass index were analysed. Comparisons were done by Chi-squared test, one-way analysis of variance and the Bonferroni's test. Prevalence of the metabolic syndrome was calculated by adapting both the WHO and the NCEP definitions of the metabolic syndrome to pregnancy. RESULTS: There were no cases of metabolic syndrome in the control group according to any of the adapted definitions. The prevalence of this syndrome was 3.3% and 10% in the late-onset gestational diabetes group, 35% and 20% in the gestational hypertension group and 30% and 30% in the preeclampsia group for the WHO and the NCEP definitions, respectively. CONCLUSIONS: Metabolic syndrome is present in about one-third of women with pregnancy-induced hypertension but only in 10% of women with late-onset gestational diabetes.