An overview of the management of diabetes from pre-conception, during pregnancy and in the postnatal period.

Diabetes is one of the most common medical conditions complicating pregnancy. Both pre-existing diabetes and gestational diabetes are associated with increased risks to the mother and fetus. These risks can be reduced by improving pre-conception and antenatal care. Pre-conception planning and care is important to ensure women are taking high dose folic acid, to optimise glucose control, to review medications and to screen for and manage any complications. All women with either pre-existing diabetes or gestational diabetes should be reviewed by the antenatal team every 1-2 weeks throughout pregnancy. This is to optimise glucose control and to monitor fetal growth and development. Women with diabetes in pregnancy should receive an individualised care plan for delivery. The exact timing of delivery will depend on maternal glucose control, fetal growth and any other complications. Women diagnosed with gestational diabetes in pregnancy are at high risk of developing both gestational diabetes and type 2 diabetes in the future. After delivery, they should be offered a fasting plasma glucose at 6 weeks or a glycated haemoglobin (HbA1c) at 13 weeks to ensure that the gestational diabetes has resolved and an annual HbA1c.

The effects of expressing antenatal colostrum in women with diabetes in pregnancy: A retrospective cohort study.

BACKGROUND: Some women with diabetes in pregnancy express and store colostrum in the antenatal period for the purposes of preventing and treating neonatal hypoglycaemia. AIMS: Our primary aim was to compare rates of neonatal hypoglycaemia in babies born to mothers who express and store antenatal colostrum to babies born to mothers who do not. MATERIALS AND METHODS: Retrospective cohort study involving 357 women with diabetes in pregnancy, who had live, singleton births delivered after 36 weeks gestation, in a regional hospital in North Queensland (2014-2015). Multivariable binary logistic regression modelling identified independent characteristics associated with primary outcomes. RESULTS: Eighty women (23%) expressed antenatal colostrum and 223 (62%) did not. One hundred and thirty-one babies (37%) were diagnosed with hypoglycaemia. Aboriginal and Torres Strait Islander women were less likely to express than Caucasian women (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01-0.77). There were no significant differences in the rates of hypoglycaemia, or median blood glucose levels in babies born to mothers who expressed antenatal colostrum compared to babies born to mothers who did not express. Babies born to mothers who expressed were significantly less likely to receive formula in hospital compared to babies born to mothers who did not (OR 0.12, 95% CI 0.05-0.32). CONCLUSIONS: We found no independent association of expressing antenatal colostrum on rates of neonatal hypoglycaemia or median blood glucose levels. Expressing antenatal colostrum may have some benefits to the newborn such as reduced formula consumption in hospital. Further research into other methods of reducing neonatal hypoglycaemia appears warranted.

Comparing outcomes of nutrition therapy, insulin and oral anti-diabetics in managing diabetes mellitus in Pregnancy: Retrospective study and review of current guidelines.

AIMS: This study aims to evaluate the glycemic profile and outcomes of Indonesian diabetic pregnant mothers based on their methods of therapy and review current international as well as national guidelines on management of diabetes in pregnancy. MATERIALS AND METHODS: Data was obtained from medical records of Hermina-Podomoro Hospital. Subjects were grouped based on therapy - nutrition therapy only, insulin and oral anti-diabetics group. RESULTS: Forty-five subjects were obtained with an average age of 31-years. Around thirty-five percent of patients were given nutrition therapy only, 55.6% were using insulin and 8.8% were using oral anti-diabetics. Oral anti-diabetics users showed worse glycemic profile among the three groups. Six-patients suffered from IUFD with the highest proportion found in oral anti-diabetics users. CONCLUSION: The above results show the negative impacts of DM on pregnant mothers and the unborn. Caution is advised on the use of oral anti-diabetics as it may increase the risk of infant mortality. Increased monitoring and prenatal services for DM patients are essential in achieving blood glucose targets.

Clinical Management of Women with Monogenic Diabetes During Pregnancy.

PURPOSE OF REVIEW: Monogenic diabetes accounts for 1-2% of all diabetes cases, but is frequently misdiagnosed as type 1, type 2, or gestational diabetes. Accurate genetic diagnosis directs management, such as no pharmacologic treatment for GCK-MODY, low-dose sulfonylureas for HNF1A-MODY and HNF4A-MODY, and high-dose sulfonylureas for KATP channel-related diabetes. While diabetes treatment is defined for the most common causes of monogenic diabetes, pregnancy poses a challenge to management. Here, we discuss the key issues in pregnancy affected by monogenic diabetes. RECENT FINDINGS: General recommendations for pregnancy affected by GCK-MODY determine need for maternal insulin treatment based on fetal mutation status. However, a recent study suggests macrosomia and miscarriage rates may be increased with this strategy. Recent demonstration of transplacental transfer of sulfonylureas also raises questions as to when insulin should be initiated in sulfonylurea-responsive forms of monogenic diabetes. Pregnancy represents a challenge in management of monogenic diabetes, where factors of maternal glycemic control, fetal mutation status, and transplacental transfer of medication must all be taken into consideration. Guidelines for pregnancy affected by monogenic diabetes will benefit from large, prospective studies to better define the need for and timing of initiation of insulin treatment.

Implementation of a diabetes in pregnancy clinical register in a complex setting: Findings from a process evaluation.

BACKGROUND: Rates of diabetes in pregnancy are disproportionately higher among Aboriginal than non-Aboriginal women in Australia. Additional challenges are posed by the context of Aboriginal health including remoteness and disadvantage. A clinical register was established in 2011 to improve care coordination, and as an epidemiological and quality assurance tool. This paper presents results from a process evaluation identifying what worked well, persisting challenges and opportunities for improvement. METHODS: Clinical register data were compared to the Northern Territory Midwives Data Collection. A cross-sectional survey of 113 health professionals across the region was also conducted in 2016 to assess use and value of the register; and five focus groups (49 healthcare professionals) documented improvements to models of care. RESULTS: From January 2012 to December 2015, 1,410 women were referred to the register, 48% of whom were Aboriginal. In 2014, women on the register represented 75% of those on the Midwives Data Collection for Aboriginal women with gestational diabetes and 100% for Aboriginal women with pre-existing diabetes. Since commencement of the register, an 80% increase in reported prevalence of gestational diabetes among Aboriginal women in the Midwives Data Collection occurred (2011-2013), prior to adoption of new diagnostic criteria (2014). As most women met both diagnostic criteria (81% in 2012 and 74% in 2015) it is unlikely that the changes in criteria contributed to this increase. Over half (57%) of survey respondents reported improvement in knowledge of the epidemiology of diabetes in pregnancy since establishment of the register. However, only 32% of survey respondents thought that the register improved care-coordination. The need for improved integration and awareness to increase use was also highlighted. CONCLUSION: Although the register has not been reported to improve care coordination, it has contributed to increased reported prevalence of gestational diabetes among high risk Aboriginal women, in a routinely collected jurisdiction-wide pregnancy dataset. It has therefore contributed to an improved understanding of epidemiology and disease burden and may in future contribute to improved management and outcomes. Regions with similar challenges in context and high risk populations for diabetes in pregnancy may benefit from this experience of implementing a register.

Prenatal visit utilization and outcomes in pregnant women with type II and gestational diabetes.

OBJECTIVE: To investigate the association between the number of prenatal visits (PNVs) and pregnancy outcomes in women with gestational diabetes (GDM) and Type 2 diabetes mellitus (DM). STUDY DESIGN: A 4-year prospective cohort study of women with GDM and DM and was conducted. Patients ⩾75th percentile for number of PNVs were compared with those ⩽25th percentile. The primary outcomes were large for gestational age (LGA) with birth weight >90% and neonatal intensive care unit (NICU) admission for >24 h. Secondary neonatal outcomes included severe LGA (>95%), shoulder dystocia, hyperbilirubinemia requiring phototherapy, neonatal hypoglycemia, low 5 min APGAR score (<7) and preterm birth (prior to 37 weeks). Secondary maternal outcomes included mean third trimester fasting blood glucose, hemoglobin A1c (Hgb A1c) in labor, preeclampsia, gestational weight gain over Institute of Medicine recommendations, mode of delivery and maternal readmission within 30 days. Logistic regression was used to adjust for maternal race, nulliparity and body mass index. RESULTS: Of the 305 women, 4 were excluded for unknown number of PNVs. Among the 301 included, the average number of visits was 12. Rates of LGA were similar between the high (28%) compared with low (18%) utilization groups (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 0.81-3.54). The high utilization group was 85% less likely to deliver an infant requiring NICU admission (aOR 0.15; 95% CI 0.04-0.53) and 59% less likely to have a preterm birth (aOR 0.41; 95% CI 0.21-0.80). A time-to-event analysis to account for the fact that patients who delivered earlier had fewer weeks to experience PNVs showed that the risk for NICU admission was still significantly lower in the high PNV utilization group (hazard ratio 0.15; 95% CI 0.04-0.51) after adjusting for confounders in a Cox proportional hazard model. The mean Hgb A1c at the time of delivery was significantly better in the high (6.4%) compared with low (6.9%) utilization groups (P=0.01). There were no differences in other maternal outcomes based on prenatal care utilization. CONCLUSIONS: Diabetic women with high PNV utilization have better glycemic control in the 3 months prior to delivery and are significantly less likely to deliver preterm infants or infants requiring NICU admission. There may be innovative ways to provide prenatal care for GDM and DM to optimize maternal and neonatal outcomes.

Asistencia a la gestante con diabetes. Guía de práctica clínica actualizada en 2014 / Care of pregnancies complicated by diabetes. Clinical practice guidelines: 2014 update

La diabetes es una de las complicaciones metabólicas más frecuentes de la gestación y se asocia a un incremento del riesgo de morbimortalidad maternal y fetal, que pueden evitarse y/o reducirse con un adecuado control. En la diabetes pregestacional, la preparación específica previa a la gestación es indispensable para intentar conseguir un control glucémico lo más próximo a la normalidad, evaluar complicaciones y revisar las pautas de tratamientos farmacológicos. En el caso de la diabetes gestacional, el tratamiento de esta entidad ha demostrado disminuir la tasa de complicaciones maternas y perinatales, por lo que su diagnóstico está justificado. En relación con la estrategia diagnóstica, ante la falta de consenso y la controversia desatada tras la aparición de los nuevos criterios IADPSG, el grupo ha decidido mantener la misma estrategia diagnóstica en 2 pasos y con los mismos puntos de corte hasta disponer de datos sólidos que avalen la introducción de nuevos criterios

Diabetes is one of the most common metabolic complications of pregnancy, and is associated with an increased risk of maternal and foetal morbidity and mortality that can be prevented and/or reduced with adequate glycaemic control. In pre-gestational diabetes, specific preparation prior to the pregnancy is essential in order to achieve glycaemic control near to normal as possible and to evaluate complications and review pharmacologic treatment prescription. The treatment of gestational diabetes has been shown to decrease the rate of maternal and perinatal complications, thus its diagnosis is justified. As regards the diagnostic strategy and due to the lack of consensus and the controversy arising after the publication of the new International Association of the Diabetes and Pregnancy Study Groups (IADPSG), the group has decided to keep the same diagnostic strategy in two stages, and with the same cut-off points, until there are solid data available that support the introduction of new criteria

Improving health service delivery for women with diabetes in pregnancy in remote Australia: survey of care in the Northern Territory Diabetes in Pregnancy Partnership.

BACKGROUND: In the Northern Territory (NT), 38% of 3500 births each year are to Indigenous women, 80% of whom live in regional and remote areas. Compared with the general Australian population, rates of pre-existing type 2 diabetes in pregnancy are 10-fold higher and rates of gestational diabetes are 1.5-fold higher among Indigenous women. Current practices in screening for diabetes in pregnancy in remote Australia are not known. AIMS: To assess current health service delivery for NT women with diabetes in pregnancy (DIP) by surveying healthcare professionals' views and practices in DIP screening and management. MATERIALS AND METHODS: A cross-sectional survey of NT healthcare professionals providing clinical care for women with DIP was conducted based on pre-identified themes of communication, care-coordination, education, orientation and guidelines, logistics and access, and information technology. RESULTS: Of the 116 responders to the survey, 78% were primary healthcare professionals, 32% midwives and 25% general practitioners. High staff turnover was evident: of Central Australian professionals, only 33% (urban) and 18% (regional/remote) had been in their current position over 5 years. DIP screening was conducted at first antenatal visit by 66% and at 24-28-week gestation by 81%. Only 50% of respondents agreed that most women at their health service received appropriate care for DIP, and 41% of primary care practitioners were neutral or not confident in their skills to manage DIP. CONCLUSIONS: It is promising that many healthcare professionals report following new guidelines in conducting early pregnancy screening for DIP in high risk women. Several challenges were identified in healthcare delivery to a high risk population in remote Australia.

Managing type 1 diabetes mellitus in pregnancy--from planning to breastfeeding.

Type 1 diabetes mellitus in pregnant women increases the risk of adverse outcomes for mother and offspring. Careful preconception counselling and screening is important, with particular focus on glycaemic control, indications for antihypertensive therapy, screening for diabetic nephropathy, diabetic retinopathy and thyroid dysfunction, as well as review of other medications. Supplementation with folic acid should be initiated before conception in order to minimize the risk of fetal malformations. Obtaining and maintaining tight control of blood glucose and blood pressure before and during pregnancy is crucial for optimizing outcomes; however, the risk of severe hypoglycaemia during pregnancy is a major obstacle. Although pregnancy does not result in deterioration of kidney function in women with diabetic nephropathy and normal serum creatinine levels, pregnancy complications such as pre-eclampsia and preterm delivery are more frequent in these women than in women with T1DM and normal kidney function. Rapid-acting insulin analogues are considered safe to use in pregnancy and studies on long-acting insulin analogues have provided reassuring results. Immediately after delivery the insulin requirement declines to approximately 60% of the prepregnancy dose, and remains 10% lower than before pregnancy during breastfeeding.

Mother/daughter relationships during pregnancy and the transition to motherhood of women with pre-existing diabetes: raising some issues.

In pregnancies complicated by pre-existing diabetes, there is a higher incidence of adverse pregnancy outcome. Several reports including the Confidential Enquiry into Maternal and Child Health, Diabetes in Pregnancy--are we providing the best care? (2007) highlighted the need for family involvement before/during pregnancy and in early motherhood with the aim of making pregnancy and the transition to motherhood a positive and fulfilling experience. Exploring the midwifery, sociological and diabetes literature may assist in gaining a better understanding of the complexities surrounding conception, pregnancy, childbirth and motherhood within the context of diabetes.

The pregnancies of women with Type 2 diabetes: poor outcomes but opportunities for improvement.

AIM: To compare the outcomes of Type 1 and Type 2 diabetic pregnancies and identify risk factors for poor outcome of Type 2 pregnancies METHODS: The data from all (389 Type 1 and 146 Type 2) pre-gestational diabetic pregnancies from 10 UK hospitals were collected prospectively. RESULTS: The Type 2 mothers were less likely to have documented pre-pregnancy counselling (28.7 vs. 40.5%; P<0.05) or be taking folic acid at conception (21.9 vs. 36.4%; P<0.001) than Type 1 mothers. The percentage of pregnancies having a serious adverse outcome was higher in Type 2 patients (16.4 vs. 6.4%; P=0.002). Congenital abnormalities (12.3% in Type 2 vs. 4.4% in Type 1; P=0.002) accounted for most of this difference. The HbA1c of the Type 2 patients was similar to that of the Type 1 with mean first trimester HbA1c of 7.22 and 7.35%, respectively (P=0.5). Treatment with oral hypoglycaemic agents [odds ratio (OR), 1.8; 95% confidence interval (CI), 1.0-3.3; P=0.04], body mass index (OR, 1.09; 95% CI, 1.01-1.18; P=0.02) and folic acid supplementation (OR, 0.3; 95% CI, 0.09-1.0; P=0.04) were all independently associated with congenital malformation. CONCLUSION: Type 2 diabetic pregnancies are characterized by poor pre-pregnancy planning, inadequate folic acid supplementation and treatment with oral hypoglycaemic agents, all of which may contribute to the serious adverse outcomes affecting one in six Type 2 diabetic pregnancies. These remediable aspects of the pre-pregnancy care of women with Type 2 diabetes provide opportunities for improving the outcome towards that of women with Type 1 diabetes.

Diabetes in pregnancy: efficacy and cost of hospitalization as compared with ambulatory management--a prospective controlled study.

BACKGROUND: Pregnant diabetic women are often subjected to frequent and prolonged hospitalizations to assure tight glycemic control, but in recent years attempts have been made at ambulatory control. The financial and social advantages of ambulatory management are obvious, but no report to date has prospectively compared its efficacy with that of hospitalization. OBJECTIVES: To evaluate the efficacy and cost of ambulatory care as compared to repeated hospitalizations for management of diabetes in pregnancy. METHODS: We conducted an 8 year prospective controlled study that included 681 diabetic women, experiencing 801 singleton pregnancies, with commencement of therapy prior to 34 gestational weeks. During 1986-1989, 394 pregnancies (60 pregestational diabetes mellitus and 334 gestational diabetes mellitus) were managed by hospitalization, and for the period 1990-1993, 407 pregnancies (61 PGDM and 346 GDM) were managed ambulatorily. Glycemic control, maternal complications, perinatal mortality, neonatal morbidity and hospital cost were analyzed. RESULTS: There was no difference in metabolic control and pregnancy outcome in women with PGDM between the hospitalized and the ambulatory groups. Patients with GDM who were managed ambulatorily had significantly lower mean capillary glucose levels, later delivery and higher gestational age at induction of labor as compared to their hospitalized counterparts. In this group there were also lower rates of neonatal hyperbilirubinemia, phototherapy and intensive care unit admissions and stay. The saved hospital cost (in Israeli prices) in the ambulatory group was $6,000 and $15,000 per GDM and PGDM pregnancy, respectively. CONCLUSIONS: Ambulatory care is as effective as hospitalization among PGDM patients and more effective among GDM patients with regard to glycemic control and neonatal morbidity. This is not only more convenient for the pregnant diabetic patient, but significantly reduces treatment costs.

Use of cod liver oil during pregnancy associated with lower risk of Type I diabetes in the offspring.

AIMS/HYPOTHESIS: To test whether cod liver oil or vitamin D supplements either taken by the mother during pregnancy or by the child in the first year of life is associated with lower risk of Type I (insulin-dependent) diabetes mellitus in children. METHODS: We carried out a population-based case control study in Vest-Agder county of Norway, evaluating the use of supplements by a mailed questionnaire. We received responses from 85 diabetic subjects and 1,071 control subjects. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using logistic regression analyses. RESULTS: When mothers took cod liver oil during pregnancy their offspring had a lower risk of diabetes. The unadjusted OR was 0.30, 95% CI: (0.12 to 0.75), p = 0.01. This association changed very little and was still significant after adjusting for age, sex, breastfeeding and maternal education. Mothers taking multivitamin supplements during pregnancy [adjusted OR= 1.11, 95% CI: (0.69 to 1.77)], infants taking cod liver oil in the first year of life [adjusted OR = 0.82, 95 % CI: (0.47 to 1.42) and the use of other vitamin D supplements in the first year of life [adjusted OR = 1.27, 95 % CI: (0.70 to 2.31)] was not [corrected] significantly associated with the risk of diabetes. CONCLUSION/INTERPRETATION: We found that cod liver oil taken during pregnancy was associated with reduced risk of Type I diabetes in the offspring. This suggests that vitamin D or the n-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid in the cod liver oil, or both, have a protective effect against Type I diabetes.

Biofeedback-assisted stress management for insulin-treated diabetes mellitus.

Six insulin-treated diabetic patients (four with type I and two with type II) who completed a biofeedback-assisted stress management program based on family systems theory improved their response to life stressors, and none had negative side effects. Four decreased their insulin requirement, including one who remained stable even during two pregnancies; the sixth became stable and discontinued drug abuse. All started biofeedback for reasons other than diabetes. Follow-ups of some individuals extend over 4 years.