Controversies in the treatment of diabetes in pregnancy- how to define well controlled?
Insulin pump treatment and insulin sensitivity during pregnancy: gestational vs. pre-existing diabetes
Abstract
Background and Aims / Part 1
Optimal metabolic control is important for favorable pregnancy outcomes in gestational diabetes (GD), pre-existing type 1 (pT1D) or type 2 diabetes (pT2D).
Methods / Part 2
During pregnancy, the fetal and placental growth induces hyperinsulinemia and insulin resistance (IR). Women with pT1D are most insulin sensitive during early stages of pregnancy, making them prone to hypoglycaemia. After 16 weeks of gestation, IR and insulin requirement increase rapidly, requiring tight glucose monitoring. American Diabetes Assosiation suggested a very narrow range for glycemic targets in pregnancy. In that context, continuous glucose monitoring (CGM) should be prioritized over self glucose monitoring because of significant improvement of glycemic control and neonatal outcomes in GD, pT1D or pT2D.
Results / Part 3
The new consensus in CGM has recommended a target range of 3.5-7.8 mmoL/L and more than 16 hours time in range (TIR) for pT1D. However, there is a lack of evidence on CGM targets for GD or pT2D. Multiple-daily injections of insulin (MDI) and continuous subcutaneous insulin infusion (CSII) are both effective approaches in GD, pT1D or pT2D. Randomised trials did not show superiority of CSII over MDI on glycemic control suggesting CGM as beneficial tool to extend TIR. Previous studies showed improvement of glycemic control by CSII in GD and pT2D, epsecially obese, with higher insulin requirement suggesting increased IR. CSII augmented by CGM favours optimal metabolic control and positive neonatal outcomes.
Conclusions / Part 4
Closed-loop delivery systems may be promising in the management of diabetes in pregnancy, but glucose targets are not customizable and currently are too high for pregnancy.
The use of automated insulin delivery (AID) in type 1 diabetes pregnancy
Maternal and neonatal long- term outcome after pregnancy complicated with diabetes
Abstract
Background and Aims
Pregnancy occurs relatively early in a woman's lifespan. Experiencing a complicated pregnancy with Gestational diabetes mellitus (GDM) can uniquely serve as an early indicator of future maternal non-communicable disease, and therefore can offer an opportunity to initiate meaningful risk reduction strategies.
Methods
A critically reviewed data from studies regarding long-term consequences (both mother and offspring).
Results
Gestational diabetes mellitus (GDM) is an independent risk factor for future longer-term risk of type 2 diabetes mellitus (T2DM), metabolic syndrome, cardiovascular morbidity, malignancies, ophthalmic, psychiatric, and renal disease in the mother. Offspring risk long-term adverse health outcomes, including T2DM, subsequent obesity, impacted neurodevelopmental outcome, increased neuropsychiatric morbidity, and ophthalmic disease.
Conclusions
Although only scarce evidence exists on the long-term effectiveness of risk-reduction interventions, the postpartum period should still be the focus for actions such as lifestyle modification (optimal weight goals, exercise, smoking cessation) and controlling for cardio-metabolic risk factors (blood pressure, glucose, lipids and weight gain) that may help abate the development of future cardio-vascular diseases, as early as their pre-clinical stage.