Prediction and prevention of preeclampsia in women with preexisting diabetes: the role of home blood pressure, physical activity, and aspirin.

Women with type 1 or type 2 (preexisting) diabetes are four times more likely to develop preeclampsia compared with women without diabetes. Preeclampsia affects 9%-20% of pregnant women with type 1 diabetes and 7%-14% of pregnant women with type 2 diabetes. The aim of this narrative review is to investigate the role of blood pressure (BP) monitoring, physical activity, and prophylactic aspirin to reduce the prevalence of preeclampsia and to improve pregnancy outcome in women with preexisting diabetes. Home BP and office BP in early pregnancy are positively associated with development of preeclampsia, and home BP and office BP are comparable for the prediction of preeclampsia in women with preexisting diabetes. However, home BP is lower than office BP, and the difference is greater with increasing office BP. Daily physical activity is recommended during pregnancy, and limiting sedentary behavior may be beneficial to prevent preeclampsia. White coat hypertension in early pregnancy is not a clinically benign condition but is associated with an elevated risk of developing preeclampsia. This renders the current strategy of leaving white coat hypertension untreated debatable. A beneficial preventive effect of initiating low-dose aspirin (150 mg/day) for all in early pregnancy has not been demonstrated in women with preexisting diabetes.

Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding.

In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m2. Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.

Comparison of Glycemic Metrics Measured Simultaneously by Intermittently Scanned Continuous Glucose Monitoring and Real-Time Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes.

Background: We aimed to compare clinically important glycemic metrics with focus on mean sensor glucose and time-below-target range (TBR) during nighttime obtained with intermittently scanned continuous glucose monitoring (isCGM) and real-time CGM (rtCGM) in early pregnancy in women with type 1 diabetes. Materials and Methods: A prospective, observational study including 20 women with type 1 diabetes simultaneously monitored with isCGM (Freestyle Libre; Abbott) and rtCGM (Envision™ Pro; Medtronic) for 7 days in early pregnancy. Time-in-target range (TIR) was defined as 3.5-7.8 mmol/L. Results: Gestational age was median 66 (interquartile range 63-74) days and HbA1c was 48 mmol/mol (43-54). Median difference between isCGM and rtCGM was 0.1 mmol/L (-0.1 to 0.5) (P = 0.50) and -0.1 mmol/L (-0.4 to 0.2) (P = 0.35) for 24 h and during nighttime, respectively. For 24 h, TBR was 3.9% (1.6-7.0) versus 2.0% (0.6-3.7) (P = 0.06) and TIR was 57.2% (50.8-76.5) versus 69.6% (55.4-81.5) (P = 0.001) for isCGM and rtCGM, respectively. During nighttime TBR was 6.5% (0.4-16.7) versus 0% (0.0-0.8) (P = 0.003), TIR was 55.4 (41.1-81.0) versus 68.8 (52.4-80.3) (P = 0.005) and 75% versus 40% of the women had ≥1 glucose reading <3.5 mmol/L. Conclusions: In pregnant women with type 1 diabetes, mean sensor glucose was reported similar when measured by isCGM and rtCGM. However, during nighttime isCGM measured a clinically relevant higher percentage of TBR compared with rtCGM. Thus, the type of CGM device used may influence adjustments of insulin dose based on the concern for nocturnal hypoglycemia. ClinicalTrials.gov (NCT03770767).

CopenFast trial: Faster-acting insulin Fiasp versus insulin NovoRapid in the treatment of women with type 1 or type 2 diabetes during pregnancy and lactation - a randomised controlled trial.

INTRODUCTION: Faster-acting insulin aspart (Fiasp) is approved for use in pregnancy and lactation, but no clinical study has evaluated its effects during this life stage in women with pre-existing diabetes. The aim of the CopenFast trial is to evaluate the effect of Fiasp compared with insulin aspart (NovoRapid) on maternal glycaemic control during pregnancy, delivery and lactation and on fetal growth and infant health. METHODS AND ANALYSIS: An open-label randomised controlled trial of pregnant women with type 1 or type 2 diabetes including women on multiple daily injection (MDI) therapy or insulin pump therapy. During a 2-year inclusion period, approximately 220 women will be randomised 1:1 to Fiasp or NovoRapid in early pregnancy and followed until 3 months after delivery. At 9, 21 and 33 gestational weeks and during planned induction of labour or caesarean section, women are offered blinded continuous glucose monitoring (CGM) for 7 days. Randomisation will stratify for type of diabetes and insulin treatment modality (MDI or insulin pump therapy, respectively). Health status of the infants will be followed until 3 months of age. The primary outcome is birth weight SD score adjusted for gestational age and gender. Secondary outcomes include maternal glycaemic control including glycated haemoglobin, preprandial and postprandial self-monitored plasma glucose levels, episodes of mild and severe hypoglycaemia, maternal gestational weight gain and weight retention, CGM time spent in, above and below target ranges as well as pregnancy outcomes including pre-eclampsia, preterm delivery, perinatal mortality and neonatal morbidity. Data analysis will be performed according to the intention-to-treat principle. ETHICS AND DISSEMINATION: The trial has been approved by the Regional Ethics Committee (H-19029966) on 7 August 2019. Results will be sought disseminated in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION NUMBER: NCT03770767.

Diabetes Management During Breastfeeding in Women with Type 1 Diabetes.

PURPOSE OF REVIEW: To provide an update on glycemic management of type 1 diabetes during breastfeeding with focus on diet and insulin treatment to prevent hypoglycemia, ketoacidosis, and weight retention. Recommendations for insulin pump settings are given. RECENT FINDINGS: Women with type 1 diabetes are encouraged to breastfeed. Hypoglycemia is a concern in the breastfeeding period among women with type 1 diabetes, and ketoacidosis may also occur. The usual goals for glucose values for persons with diabetes also apply during breastfeeding. The recommended minimum daily carbohydrate intake is 210 g during breastfeeding, and this may contribute to prevention of hypoglycemia and ketoacidosis while aiming for gradual weight loss. Insulin requirements are 21% lower during breastfeeding than before pregnancy. Diabetes management in breastfeeding women with type 1 diabetes includes the same goals for glucose values as in other persons with diabetes, sufficient carbohydrate intake, and adequate reduction in insulin dose.

Insulin Pump Settings During Breastfeeding in Women with Type 1 Diabetes.

Background: We aimed to explore insulin pump settings in breastfeeding women with type 1 diabetes. Methods: Thirteen unselected breastfeeding women with type 1 diabetes on insulin pump therapy were included consecutively from April 2016 to October 2017. Blinded continuous glucose monitoring (CGM) for 6 days was applied at 1, 2, and 6 months after delivery. Recommendations were intake of 210 g carbohydrate daily while aiming for glucose target range 4.0-10.0 mmol/L and avoiding hypoglycemia. Immediately after delivery a reduction of total insulin dose by 30% of the prepregnancy dose was recommended. Insulin pump target glucose was 5.8 mmol/L. Results: Median diabetes duration was 22 (range 13-36) years. At 1, 2, and 6 months, 13, 11, and 8 women, respectively, were breastfeeding and spent ≥70.8% (25%-99%) of time in the glucose target range and ≤3.8% (0%-15.5%) of time with CGM <4.0 mmol/L at night-time and for 24 h. None of the women experienced severe hypoglycemia. HbA1c was 58 (47-72) mmol/mol and 52 (44-60) at 6 months and prepregnancy, respectively, P = 0.18. At 1, 2, and 6 months, the insulin pump settings remained almost stable with basal insulin rates (at 03.00, 08.00, 12.00, and 18.00) 14% lower and the carbohydrate-to-insulin ratios 10% higher than the prepregnancy settings. Conclusions: In breastfeeding women with type 1 diabetes who consumed sufficient amounts of carbohydrates and obtained appropriate glycemic control, the basal insulin rates were 14% lower and carbohydrate-to-insulin ratios 10% higher than before pregnancy. These data are useful when recommending insulin pump settings after delivery.

Diastolic blood pressure is a potentially modifiable risk factor for preeclampsia in women with pre-existing diabetes.

AIMS: To identify early clinical, modifiable risk factors for preeclampsia present at first antenatal visit and assess the prevalence of pregnancy-related hypertensive disorders in women with pre-existing diabetes treated with tight glycemic and blood pressure (BP) control. METHODS: A population-based cohort study of 494 women with pre-existing diabetes (307 and 187 women with type 1 and type 2 diabetes, respectively), included at their first antenatal visit from 2012 to 2016. The prevalence of chronic hypertension (without diabetic nephropathy or microalbuminuria), gestational hypertension and preeclampsia was recorded. Diabetic microangiopathy included presence of nephropathy, microalbuminuria and/or retinopathy. Treatment target was BP <135/85 mmHg. RESULTS: HbA1c was 6.9 ±â€¯2.4% (50 ±â€¯12 mmol/mol) at first antenatal visit and 6.0 ±â€¯0.6% (43 ±â€¯6 mmol/mol) before delivery with no differences between women with type 1 and type 2 diabetes. At the first antenatal visit, the prevalence of microalbuminuria was 6% (6% vs. 6%), nephropathy 2% (1% vs. 2%) and chronic hypertension 6% (3% vs. 10%, p = 0.03). Gestational hypertension developed in 8% (9% vs. 6%) and preeclampsia developed in 8% (9% vs. 7%). Presence of diabetic microangiopathy (adjusted odds ratio (OR) 4.35 (confidence interval 2.12-8.93)) and diastolic BP (adjusted OR 1.72 per 10 mmHg (1.05-2.82)) at the first antenatal visit were independent risk factors for preeclampsia. CONCLUSIONS: At the first antenatal visit, diastolic BP was the only independent, potentially modifiable risk factor for preeclampsia in women with pre-existing diabetes in the context of tight glycemic and BP control. One out of four women had hypertensive disorders during pregnancy.

Use of the smartphone application "Pregnant with Diabetes".

INTRODUCTION: The aim of this article was to evaluate the awareness and use of the smartphone application (app) "Pregnant with Diabetes" locally, nationally and internationally. METHODS: In 2013, a patient initiated collaboration with the staff at Centre for Pregnant Women with Diabetes, Rigs-hospitalet, to develop the app "Pregnant with Diabetes". The app communicates clinically important antenatal health information to women with diabetes, based on recommendations from our centre. Women with pre-existing diabetes (Type 1 and Type 2 diabetes) completed an anonymous, structured questionnaire at their first antenatal visit in early pregnancy at our centre. National and international data on numbers of downloads were obtained from Google Play, from the App Store and from Google Analytics. RESULTS: Among 139 pregnant women with diabetes (96 with Type 1 diabetes and 43 with Type 2 diabetes), 99% had a smartphone and 75% had downloaded the app, whereof 48% had obtained information from the app before their pregnancy. In July 2017, the app had been downloaded 4,465 times in Denmark and 27,361 times in a total of 183 countries. The topics most frequently visited were "diet and carbohydrates", "blood glucose" and "possible complications". CONCLUSIONS: Easily accessible patient information made available via app technology reaches the patients and may contribute to improved pregnancy planning and outcome in women with pre-existing diabetes - locally, nationally and internationally. FUNDING: The app was sponsored by Novo Nordisk, Bayer A/S, Diabetes Care, Abbott, MSD Denmark, A.D.I.P.S and Rigshospitalet. TRIAL REGISTRATION: not relevant.