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.     

New strategies for glucose control in patients with type 1 and type 2 diabetes mellitus in pregnancy

Over the past 5 decades, perinatal outcome in pregnancies complicated by diabetes mellitus has improved dramatically due in large part to better maternal glycemic control. Self-blood glucose monitoring in combination with flexible or intensive insulin treatment including the use of newer insulin analogs and insulin pump therapy has dramatically improved glucose control in most pregnancies complicated by diabetes. In developing an insulin regimen, careful attention must be paid to both basal and prandial insulin needs. Every effort must be made to avoid hypoglycemia and prevent ketoacidosis. A team approach including the patient, diabetes nurse educator, nutritionist, and social worker is ideal.     

Management of diabetes mellitus complicating pregnancy

Diabetes mellitus complicates 3-5% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal morbidity. The availability of a variety of new insulins, the insulin pump, and self-monitoring of blood glucose have revolutionized the care of the pregnancy complicated by diabetes mellitus. However, challenges remain in caring for the pregnant patient with pregestational diabetes. Relatively few women receive preconceptional counseling, and major fetal malformations as a result of poor glucose control before and during the early weeks of gestation have emerged as the major cause of perinatal mortality. When the patient has diabetic vasculopathy, the obstetrician, maternal-fetal specialist, and/or endocrinologist and other members of the health care team must perform a challenging balancing act that promotes fetal health while minimizing maternal risk. As obesity increases in this country and our population becomes more diversified, the rate of gestational diabetes mellitus (GDM) will rise. Although there is controversy regarding which diagnostic standards to use for GDM, there is agreement that excellent blood glucose control, with diet and, when necessary, insulin will result in improved perinatal outcome. Finally, the goal of our educational programs should be not only to improve pregnancy outcome but also to promote healthy lifestyle changes for the mother that will last long after delivery.     

Type 2 diabetes in pregnancy: exposing deceptive appearances.

Now that we have been forewarned of the growing pandemic of type 2 diabetes and obesity in pregnancy, we need to become forearmed. Over the past few decades there has been no significant improvement in perinatal outcome complicated by diabetes mellitus (type 1 and type 2). The recognition of modifiable risk factors such as maternal glycemic control using self-monitoring blood glucose in combination with pharmacological therapy (intensified therapy) and weight gain in pregnancy should enhance pregnancy outcome. The overemphasis and concentration on the non-modifiable risk factors in pregnancy is a futile pursuit that may generate lively discussion but paucity of results. The focus needs to be in education for the care provider, i.e., enhanced recognition of this growing entity and a heightened awareness of the need for pre-pregnancy counseling about preconception glycemic control. Another center of attention should be the dissemination of information to patients of the impending maternal and fetal risks of type 2 diabetes in pregnancy. This care would include antenatal care for surveillance of maternal diabetes complications as well as careful obstetric surveillance to improve maternal and fetal outcomes.     

Type 2 diabetes in pregnancy: Exposing deceptive appearances

Now that we have been forewarned of the growing pandemic of type 2 diabetes and obesity in pregnancy, we need to become forearmed. Over the past few decades there has been no significant improvement in perinatal outcome complicated by diabetes mellitus (type 1 and type 2). The recognition of modifiable risk factors such as maternal glycemic control using self-monitoring blood glucose in combination with pharmacological therapy (intensified therapy) and weight gain in pregnancy should enhance pregnancy outcome. The overemphasis and concentration on the non-modifiable risk factors in pregnancy is a futile pursuit that may generate lively discussion but paucity of results. The focus needs to be in education for the care provider, i.e., enhanced recognition of this growing entity and a heightened awareness of the need for pre-pregnancy counseling about preconception glycemic control. Another center of attention should be the dissemination of information to patients of the impending maternal and fetal risks of type 2 diabetes in pregnancy. This care would include antenatal care for surveillance of maternal diabetes complications as well as careful obstetric surveillance to improve maternal and fetal outcomes.     

孕期血糖监测频率对饮食控制的妊娠期糖尿病围产结局的影响

目的:探讨血糖监测频率对饮食控制的妊娠期糖尿病(GDM)孕妇围产结局的影响。方法:选取2015年11月至2018年4月在浙江大学医学院附属妇产科医院产检并分娩单胎、孕前无糖尿病高血压疾病的5453例饮食控制的GDM孕妇。根据OGTT试验时的血糖水平将孕妇分为高危组2699例(49.5%)和低危组2754例(50.5%)。分别在高危和低危组中比较不同血糖监测频率组间临床资料及围产结局差异。采用单因素方差分析、χ2检验及二元logistic回归分析对数据进行统计分析。结果:高危组孕妇的平均年龄(33.21±4.50)岁vs(32.30±4.34)岁、孕前BMI(21.77±3.38)kg/m2 vs(21.26±3.20)kg/m2、经产妇比例(51.0%vs 47.9%)、糖尿病家族史(4.4%vs 3.3%)及巨大儿生产史比例(5.2%vs 4.1%)均显著高于低危组孕妇(P均<0.05),两组间血糖监测频率无显著差异。在围产结局方面,高危组孕妇的早产(10.8%vs 8.8%)及初次剖宫产比例(35.9%vs 31.3%)均显著高于低危组孕妇(P均<0.05)。高危组孕妇中,大于胎龄儿的发生率与血糖监测频率呈负相关(P<0.05);与从不监测血糖相比,偶尔监测和定期监测血糖均为大于胎龄儿的负相关独立影响因素(P<0.05,OR=0.708、0.644)。低危组孕妇中,不同血糖监测频率组间大于胎龄儿发生率差异无统计学意义。无论在低危还是高危孕妇中,其围产结局发生率在各血糖监测频率组间差异无统计学意义。结论:对于饮食控制的GDM孕妇,应在评估其高危程度后拟定个体化血糖监测方案。对于低危孕妇,单纯增加血糖监测频率对围产结局无明显助益;对于高危孕妇,增加血糖监测频率可显著减少大于胎龄儿的发生。     

孕前糖尿病合并妊娠临床管理新进展

孕前糖尿病合并妊娠母儿不良结局增加。孕前糖尿病孕妇计划妊娠是避免和减少胎儿先天畸形等的重要一步。推荐的糖化血红蛋白控制目标孕前为<6.5%,孕期为<6.0%。糖尿病合并症的筛查及管理至关重要,血压控制目标应更谨慎,尤其是有糖尿病肾脏疾病者。对于1型糖尿病患者,孕期动态血糖监测有助于改善血糖控制水平。胰岛素是孕期糖尿病患者的一线治疗方案。优化血糖控制和药物治疗方案,并密切关注并发症,能够降低孕前糖尿病合并妊娠的母儿不良结局风险,并确保孕前、妊娠期间和产后的糖尿病管理质量。     

Home Blood Glucose Monitoring in the Pregnant Diabetic

The development of testing materials that offer a safe, simple, and relatively painless determination of blood glucose levels may improve control of maternal diabetes, thereby reducing morbidity in the infant. The use of home blood glucose monitoring has reduced perinatal morbidity, and a discussion of the procedure and nursing implications is presented.     

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.     

Measuring and managing hyperglycemia in pregnancy: from glycosuria to continuous blood glucose monitoring

The need to accurately detect and monitor hyperglycemia in pregnancy is becoming more apparent as the incidence of pregestational and gestational diabetes is increasing, especially among adolescents. The risk of adverse perinatal outcome is markedly worsened when pregnancy is complicated by elevated blood glucose. The appropriate management of both pregestational and gestational diabetes as it relates to blood glucose targets is clear. In the past 5 years, a number of studies have concluded that tight glycemic control throughout pregnancy significantly reduces both fetal and maternal risk. These studies have proposed blood glucose targets between 70 to 120 mg/dL. They have concluded that blood glucose levels should be the basis of moving rapidly to more effective treatments. The key to this approach is the adoption of blood glucose monitoring as an integral part of the treatment regimen. To assure sufficient data on which clinical decisions are made, the type of device, frequency of monitoring, and interpretation of results need to be carefully considered.     

Preprandial versus postprandial blood glucose monitoring in type 1 diabetic pregnancy: a randomized controlled clinical trial

OBJECTIVE: This study was undertaken to compare preprandial and postprandial capillary glucose monitoring in pregnant women with type 1 diabetes. STUDY DESIGN: Sixty-one women with type 1 diabetes were randomly assigned at 16 weeks' gestation to preprandial or postprandial blood glucose monitoring using memory-based glucose reflectance meters throughout pregnancy. Serial measurements of hemoglobin A1c and fructosamine were obtained throughout pregnancy. Insulin, glucose, and insulin-like growth factor-I (IGF-I) were measured in cord blood at delivery. Neonatal anthropometric measures were performed within 72 hours of delivery RESULTS: Maternal age, parity, age of onset of diabetes, number of prior miscarriages, smoking status, social class, weight gain in pregnancy, and compliance with therapy were similar in the two groups. The postprandial monitoring group had a significantly reduced incidence of preeclampsia (3% vs 21%, P<.048), a greater success in achieving glycemic control targets (55% vs 30%, P<.001) and a smaller neonatal triceps skinfold thickness (4.5+/-0.9 vs 5.1+/-1.3, P=.05). CONCLUSION: Postprandial capillary blood glucose monitoring in type 1 diabetic pregnancy may significantly reduce the incidence of preeclampsia and neonatal triceps skinfold thickness compared with preprandial monitoring.     

The effect of third-trimester glycemic control on maternal and perinatal morbidities in pregestational diabetes mellitus.

From May 1974 to March 1989, 48 cases of pregestational diabetes mellitus treated during the third trimester of pregnancy at the Obstetric Clinic of the National Taiwan University Hospital had complete maternal-fetal chart, and were enrolled into this retrospective review. Of these cases, 28 were class B, 13 were class C and seven were class D-R. The maternal complications and perinatal morbidities of each class were reviewed. The mean fasting, postprandial plasma glucose concentrations and the mean excursion of plasma glucose levels were calculated for statistical analysis. Among the maternal complications, urinary tract infections and preterm labor were significantly associated with mean fasting plasma glucose concentrations. Among perinatal morbidities, neonatal respiratory distress and metabolic problems (including neonatal hyperbilirubinemia, symptomatic hypoglycemia, hypocalcemia and polycythemia) were significantly associated with mean plasma fasting glucose concentrations, and perinatal asphyxia was associated with a mean excursion of plasma glucose levels. In view of the paucity of knowledge about the etiology of complications in diabetic pregnancies, it is necessary to conduct a prospective multi-center study with well-characterized morbidities to search for the role of glycemic control in obstetric and perinatal complications.     

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.     

The correlations of glycosylated serum protein and glycosylated hemoglobin concentrations with blood glucose in diabetic pregnancy

The usefulness of concentrations of glycosylated serum protein and glycosylated hemoglobin in monitoring glycemic control during pregnancy complicated by diabetes was evaluated by correlation of these parameters with fasting and 2-hour postprandial glucose concentrations of the previous 7 days. Glycosylated serum protein correlated with both fasting (r = 0.798, p less than 0.01, n = 71) and postprandial (r = 0.846, p less than 0.01, n = 69) blood glucose concentrations. Glycosylated hemoglobin also correlated with fasting (r = 0.571, p less than 0.01, n = 71) and postprandial (r = 0.510, p less than 0.01, n = 74) blood glucose concentrations. Monitoring glycosylated serum protein during pregnancy complicated by diabetes is clinically feasible and allows frequent reappraisal of diabetic control.     

Neonatal morbidity in pregnancy complicated by diabetes mellitus: predictive value of maternal glycemic profiles

The relationship between glycemic control and perinatal outcome was assessed in a relatively uniform population of 75 White Class B through D pregnant diabetic women. All patients used glucose reflectance meter self-monitoring and performed a minimum of four determinations daily. Mean capillary blood glucose was calculated from a minimum of 16 weeks of determinations. Regression analysis confirmed a correlation between these values and third-trimester hemoglobin A1 (p less than 0.001). The study population was divided into two groups on the basis of mean capillary blood glucose values: group I, mean capillary blood glucose less than 110 mg/dl (43 patients) (mean = 96.8 +/- 7.1); group II, mean capillary blood glucose greater than 110 mg/dl (32 patients) (mean = 126 +/- 9.0). Of the 32 patients in group II, eight had mean capillary blood glucose greater than or equal to 130 mg/dl. The degree of maternal glycemic control appeared to affect perinatal outcome. At least one form of infant morbidity was present in 33% of group I infants compared with 53% of group II. Significant differences were observed for the incidence of hypoglycemia (p less than 0.05), macrosomia (p less than 0.05), and respiratory distress syndrome (p less than 0.01). One of six group I infants delivered at 35 to 36 weeks developed respiratory distress syndrome, compared with four of seven group II patients. The appearance of phosphatidylglycerol in amniotic fluid appeared delayed in group II patients at term. These data suggest that maintaining mean capillary blood glucose values less than 110 mg/dl may serve to reduce several major forms of morbidity in the infant of the diabetic mother. This information is helpful in establishing objectives for glycemic control in pregnant women using self-monitoring techniques.     

妊娠期糖尿病患者的产后管理策略

妊娠期糖尿病(gestational diabetes mellitus,GDM)患者及其子代均是2型糖尿病(type 2 diabetes mellitus,T2DM)患病的高危人群,针对这一群体进行合理干预,是预防T2DM的第一道防线.产后血糖监测和随访管理具有重要社会价值和经济效益.本文通过强化GDM母儿远期不良...     

Glycemic control in gestational diabetes mellitus--how tight is tight enough: small for gestational age versus large for gestational age?

The relationship between optimal levels of glycemic control and perinatal outcome was assessed in a prospective study of 334 gestational diabetic women and 334 subjects matched for control of obesity, race, and parity. All women with gestational diabetes mellitus were instructed in the use of a memory-based reflectance meter. They were treated with the same metabolic goal according to a predetermined protocol. Three groups were identified on the basis of mean blood glucose level throughout pregnancy (low, less than or equal to 86 mg/dl; mid, 87 to 104 mg/dl; and high, greater than or equal to 105 mg/dl). The low group had a significantly higher incidence of small-for-gestational-age infants (20%). In contrast, the incidence of large-for-gestational-age infants was 21-fold higher in the mean blood glucose category than in the low mean blood glucose category (24% vs. 1.4%, p less than 0.0001). An overall incidence of 11% small-for-gestational-age and 12% large-for-gestational-age infants was calculated for the control group. A significantly higher incidence of small-for-gestational-age infants (20% vs. 11%, p less than 0.001) was found between the control and the low category. In the high mean blood glucose category an approximate twofold increase was found in the incidence of large-for-gestational-age infants when compared with the control group (p less than 0.03). No significant difference was found between the control and mean blood glucose categories (87 to 104 mg/dl). Our data suggest that a relationship exists between level of glycemic control and neonatal weight. This information is helpful in targeting the level of glycemic control while optimizing pregnancy outcome in gestational diabetes comparable to the general population.     

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。     

Glycemic control in the diabetic pregnancy: is tighter always better?

Glucose is the principal nutrient that the mother supplies to the fetus through the placenta by way of concentration-dependent mechanisms. In the presence of maternal hypoglycemia, with limited glucose supply, fetal hypoglycemia and hypoinsulinism ensue. This may be viewed as an adaptive mechanism to increase the chances of fetal survival in the face of limited maternal supply, albeit of a growth-restricted fetus. Fetal nutrient deprivation and the resulting hypoinsulinism may have both short- and long-term consequences. Intrauterine growth failure is associated with higher rates of gestational age-specific neonatal mortality and with long-term cognitive deficits. Furthermore, epidemiologic data suggest that diabetes, coronary artery disease, and hypertension are more common among adults who were small for gestational age at birth. Thus, pancreatic failure in adulthood may be either a response to excessive exposure to glucose as a result of maternal hyperglycemia, or as a result of hypoglycemia where nutrient deprivation leads to fetal growth restriction and reduced islet cell proliferation. Because low mean concentrations of maternal glucose in gestational diabetes are associated with an increased risk of fetal growth restriction, overzealous glycemic control during pregnancy may raise concerns regarding the possible effects on the infant. In the mother with Type 1 diabetes, strict glycemic control is often associated with an increased incidence of severe hypoglycemia. Up to 40% of women report at least one episode of severe hypoglycemia during pregnancy, requiring assistance by another person or professional intervention. It is quite possible that in some patients striving to optimize pregnancy outcome by maintaining the best possible glycemic control jeopardizes the well-being of the mother and the fetus. Thus, with respect to tight glycemic control of pregnant women with diabetes, the question arises: How tight is too tight? Is there a threshold below which the trade-off in terms of maternal morbidity as well as fetal growth restriction and its consequences outweighs the benefits of preventing the effects of maternal hyperglycemia?     

Perinatal outcome of pregnancies complicated by diabetes and by maternal daily hyperglycemia not related to diabetes. A retrospective 10-year analysis

We analyzed the perinatal outcome of 1,086 pregnancies classified according to the response to the 3-hour 100-gram glucose tolerance test and the diurnal glycemic profile into the Rudge groups corresponding to control pregnant women, class A gestational diabetic women, class A/B to FRH pregnant women and women with daily hyperglycemia. Despite treatment, the diabetic pregnant women and those with daily hyperglycemia presented higher mean blood glucose levels compared to controls (76.6+/-10.2 mg/dl). The pregnancies complicated by diabetes and by daily hyperglycemia were characterized by a high incidence of prematurity, macrosomia, large for gestational age newborn infants, malformation and fetal and neonatal death, with consequent perinatal mortality. The perinatal mortality of women with daily hyperglycemia was 10 times higher than that of the controls and was similar to that of the diabetic patients. These adverse perinatal results emphasize the need for the diagnosis and control of intrauterine hyperglycemia both in diabetic pregnant women and in women with an altered diurnal glycemic profile.