Randomised Controlled Trial of a Customised Text Messaging and Activity Monitor Program for Lifestyle Improvement after Gestational Diabetes.

Gestational diabetes (GDM) is associated with a long-term risk of diabetes. We aimed to determine whether a text-messaging-based lifestyle support program would improve diabetes risk factors following GDM. Women with GDM were randomised following delivery to receive four text messages per week supporting a healthy lifestyle and parenting for 6 months, with feedback from an activity monitor (intervention), or to receive the activity monitor only (control). The primary outcome was a composite of weight, physical activity and dietary goals. There were 177 women randomised, with 88 intervention and 89 control participants. All the participants experienced COVID-19 lockdowns during the study. Six-month primary outcome data were obtained for 57 intervention participants and 56 controls. There were 7/57 (12%) intervention and 6/56 (11%) control participants who met the primary outcome (relative risk, 1.08; 95%CI, 0.63-1.85; p = 0.79). Two intervention participants met the dietary goals compared to none of the control participants (p = NS). The intervention participants were more likely to record >1000 steps/day (on 102 ± 59 vs. 81 ± 59 days, p = 0.03). When analysed monthly, this was not initially different but became significant 3-6 months post-partum. Interviews and surveys indicated that with the Intervention, healthier choices were made, but these were negatively impacted by COVID-19 restrictions. Participants found the messages motivational (74%) and the activity monitor useful (71%). In conclusion, no improvement in the diabetes risk factors occurred among the women receiving the text messaging intervention when affected by COVID-19 restrictions.

Previous High-Intensity Breastfeeding Lowers the Risk of an Abnormal Fasting Glucose in a Subsequent Pregnancy Oral Glucose Tolerance Test.

Breastfeeding is associated with reduced lifetime cardiometabolic risk, but little is known regarding the metabolic benefit in a subsequent pregnancy. The primary aim of this study was to investigate the association between breastfeeding duration and intensity and next pregnancy oral glucose tolerance test (OGTT) results. A retrospective cohort study was conducted from March 2020 to October 2022. All multiparous women who met inclusion criteria and gave birth during the study period were eligible for inclusion. Analysis was stratified by risk for gestational diabetes (GDM). High GDM risk criteria included previous GDM and BMI > 35 kg/m2. The association between breastfeeding duration and high-intensity breastfeeding (HIBF) and subsequent pregnancy OGTT were assessed with multivariate logistic models adjusted for statistically and clinically relevant covariables. There were 5374 multiparous participants who met the inclusion criteria for analysis. Of these, 61.7% had previously breastfed for >6 months, and 43.4% were at high risk for GDM. HIBF was associated with 47% reduced odds of an abnormal fasting glucose in a subsequent pregnancy OGTT (aOR 0.53; 95%CI 0.38-0.75; p < 0.01). There was no association between HIBF and other glucose results on the OGTT. Women who smoked were least likely to breastfeed at high intensity (aOR 0.31; 95%CI 0.21-0.47; p < 0.01). South Asian women had 65% higher odds of HIBF than women who identified as White/European (aOR 1.65; 1.36-2.00; p < 0.01). This study highlights the importance of exclusive breastfeeding to potentially reduce the prevalence of GDM and may also translate into long-term reduction of cardiometabolic risk.

The relationship between falling insulin requirements and serial ultrasound measurements in women with preexisting diabetes: a prospective cohort study.

INTRODUCTION: A large fall in insulin requirements (FIR) in women with diabetes is associated with adverse clinical outcomes but previous studies have not examined its relation with serial ultrasound parameters. OBJECTIVE: To determine whether FIR is associated with alteration in umbilical artery Doppler parameters and fetal growth restriction (FGR) in women with preexisting diabetes. METHODS: Serial obstetric Doppler ultrasounds were conducted 2 weekly from 28 weeks gestation in women with Type 1 and Type 2 diabetes who were being treated with insulin. Estimated fetal weight (EFW), head circumference:abdominal circumference (HC:AC) ratio and umbilical artery doppler parameters (SD ratio) and pulsatility index (PI) were measured. Information on insulin dose was collected prospectively throughout pregnancy and women with FIR ≥ 15% were considered cases. Linear mixed effect models were used to assess the association between FIR and ultrasound parameters. RESULTS: One hundred and forty two women were included in the study (type 1 diabetes n = 41, type 2 diabetes n = 101). Thirty women demonstrated FIR ≥ 15%. There was no significant difference in the change of S/D ratio or PI over the third trimester in cases with FIR ≥ 15%, compared to the rest of the cohort, before or after adjusting for type of diabetes. Likewise there was no difference in EFW and HC:AC ratio with advancing gestation before or after adjusting for variables known to influence fetal growth. FGR rates (3.3 vs 8% p = 0.298) and high S/D ratio > 95% (13.3 vs 8%, p = 0.296) were similar between the two groups. CONCLUSIONS: FIR ≥ 15% was not associated with changes in placental flow or FGR however larger studies are needed to evaluate this further.

Pregnancy outcomes in women with gestational diabetes mellitus by models of care: a retrospective cohort study.

OBJECTIVE: To compare birth outcomes of women with gestational diabetes mellitus (GDM) with background obstetric population, stratified by models of care. DESIGN: Retrospective cohort study. SETTING: A tertiary referral centre in Sydney, Australia. PARTICIPANTS: All births 1 January 2018 to 30 November 2020. Births <24 weeks, multiple gestations and women with pre-existing diabetes were excluded. METHODS: Data were obtained from electronic medical records. Women were classified according to GDM status and last clinic attended prior to delivery. Model of care included attendance at dedicated GDM obstetric clinics, and routine antenatal care. MAIN OUTCOME MEASURES: Hypertensive disorders of pregnancy (HDP), pre-term birth (PTB), induction of labour (IOL), operative delivery, small for gestational age (SGA), large for gestational age, postpartum haemorrhage, obstetric anal sphincter injury (OASIS), neonatal hypoglycaemia, neonatal hypothermia, neonatal respiratory distress, neonatal intensive care unit (NICU) admission. RESULTS: The GDM rate was 16.3%, with 34.0% of women managed in dedicated GDM clinics. Women with GDM had higher rates of several adverse outcomes. Only women with GDM attending non-dedicated clinics had increased odds of HDP (adjusted OR (adj OR) 1.6, 95% CI 1.2 to 2.0), PTB (adj OR 1.7, 95% CI 1.4 to 2.0), OASIS (adj OR 1.4, 95% CI 1.0 to 2.0), similar odds of induction (adj OR 1.0, 95% CI 0.9 to 1.1) compared with non-GDM women. There were increased odds of NICU admission (adj OR 1.5, 95% CI 1.3 to 1.8) similar to women attending high-risk GDM clinics. CONCLUSIONS: Women with GDM receiving care in lower risk clinics had similar or higher rates of adverse outcomes. Pathways of care need to be similar in all women with GDM.

The BLIiNG study - Breastfeeding length and intensity in gestational diabetes and metabolic effects in a subsequent pregnancy: A cohort study.

BACKGROUND: Gestational diabetes mellitus is associated with higher risk for developing type 2 diabetes. Breastfeeding is protective against the development of type 2 diabetes after gestational diabetes. There are no data regarding the effect of breastfeeding on the development of recurrent gestational diabetes. OBJECTIVE: Investigate the relationship of previous breastfeeding duration and intensity with the recurrence of gestational diabetes, and second pregnancy glucose tolerance test results. METHODS: We conducted a questionnaire-based pilot cohort study, enrolling 210 women during a subsequent second pregnancy, after a gestational diabetes-affected first pregnancy. Models for length and intensity of breastfeeding as predictors of the oral glucose tolerance test and for diagnosis of gestational diabetes in second pregnancy were fitted and then adjusted for possible confounders. RESULTS: Recurrent gestational diabetes rate in the study cohort was 70% (n = 146). In a fully adjusted model high intensity breastfeeding was associated with a lower 2-hour glucose level on the oral glucose tolerance test (by 0.66 mmol/L, 95% CI [0.15-1.17]; p = 0.01) and breastfeeding greater than six months with a lower 1-hour glucose on the oral glucose tolerance test (by 0.67 mmol/L, 95% CI [0.16-1.19]; p = 0.01), compared to women who breastfed less intensively or for a shorter duration respectively. There was an 18% reduction in the risk of gestational diabetes if a woman breastfed for more than six months (RR 0.82, 95% CI [0.69-0.98]; p = 0.03). The association was attenuated in the fully adjusted model (RR 0.89, 95% CI [0.78-1.02]; p = 0.09). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We found the risk of recurrent gestational diabetes was reduced by both increased duration and intensity of breastfeeding. Antenatal lactation education should be embedded into care pathways for women diagnosed with gestational diabetes.

Aspirin for the prevention of pre-eclampsia in women with pre-existing diabetes: Systematic review.

BACKGROUND: There is a lack of evidence for pre-eclampsia prophylaxis with aspirin in women with pre-existing diabetes mellitus (DM). AIMS: To examine the evidence for aspirin in pre-eclampsia prophylaxis in women with pre-existing DM. MATERIAL AND METHODS: An electronic search using Ovid MEDLINE, Embase, CinicalTrials.gov and the Cochrane CENTRAL register of controlled trials through to February 2021 was performed. Reference lists of identified studies, previous review articles, clinical practice guidelines and government reports were manually searched. Randomised controlled trials (RCTs) of aspirin vs placebo for pre-eclampsia prophylaxis were included. Articles were manually reviewed to determine if cohorts included women with DM. The systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data from included trials were extracted independently by two authors who also independently assessed risk of bias as per the Cochrane Handbook criteria version 5.1.0. Data were analysed using Rev-Man 5.4. RESULTS: Forty RCTs were identified, of which 11 included a confirmed subset of women with DM; however, data were insufficient for meta-analysis. Meta-analysis of 930 women with DM, from individual patient data included in a systematic review and unpublished data from one of the 11 RCTs, showed a non-significant difference in the outcome of pre-eclampsia in participants treated with aspirin compared to placebo (odds ratio 0.58; 95% CI 0.20-1.71; P = 0.33). CONCLUSIONS: Pre-eclampsia risk reduction with aspirin prophylaxis in women with pre-existing DM may be similar to women without pre-existing DM. However, randomised data within this meta-analysis were insufficient, warranting the need for further studies within this high-risk group of women.

Effectiveness of a customised mobile phone text messaging intervention supported by data from activity monitors for improving lifestyle factors related to the risk of type 2 diabetes among women after gestational diabetes: protocol for a multicentre randomised controlled trial (SMART MUMS with smart phones 2).

INTRODUCTION: Gestational diabetes (GDM) contributes substantially to the population burden of type 2 diabetes (T2DM), with a high long-term risk of developing T2DM. This study will assess whether a structured lifestyle modification programme for women immediately after a GDM pregnancy, delivered via customised text messages and further individualised using data from activity monitors, improves T2DM risk factors, namely weight, physical activity (PA) and diet. METHODS AND ANALYSIS: This multicentre randomised controlled trial will recruit 180 women with GDM attending Westmead, Campbelltown or Blacktown hospital services in Western Sydney. They will be randomised (1:1) on delivery to usual care with activity monitor (active control) or usual care plus activity monitor and customised education, motivation and support delivered via text messaging (intervention). The intervention will be customised based on breastfeeding status, and messages including their step count achievements to encourage PA. Messages on PA and healthy eating will encourage good lifestyle habits. The primary outcome of the study is healthy lifestyle composed of weight, dietary and PA outcomes, to be evaluated at 6 months. The secondary objectives include the primary objective components, body mass index, breastfeeding duration and frequency, postnatal depression, utilisation of the activity monitor, adherence to obtaining an oral glucose tolerance test post partum and the incidence of dysglycaemia at 12 months. Relative risks and their 95% CIs will be presented for the primary objective and the appropriate regression analysis, adjusting for the baseline outcome results, will be done for each outcome. ETHICS AND DISSEMINATION: Ethics approval has been received from the Western Sydney Local Health District Human Research Ethics Committee (2019/ETH13240). All patients will provide written informed consent. Study results will be disseminated via the usual channels including peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: ACTRN12620000615987; Pre-results.

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme.

BACKGROUND: To test the feasibility of benchmarking the care of women with pregnancies complicated by hyperglycaemia. METHODS: A retrospective audit of volunteer diabetes services in Australia and New Zealand involving singleton pregnancies resulting in live births between 2014 and 2020. Ranges are shown and compared across services. RESULTS: The audit included 10,144 pregnancies (gestational diabetes mellitus (GDM) = 8696; type 1 diabetes (T1D) = 435; type 2 diabetes (T2D) = 1013) from 11 diabetes services. Among women with GDM, diet alone was used in 39.4% (ranging among centres from 28.8-57.3%), metformin alone in 18.8% (0.4-43.7%), and metformin and insulin in 10.1% (1.5-23.4%); when compared between sites, all p < 0.001. Birth was by elective caesarean in 12.1% (3.6-23.7%) or emergency caesarean in 9.5% (3.5-21.2%) (all p < 0.001). Preterm births (<37 weeks) ranged from 3.7% to 9.4% (p < 0.05), large for gestational age 10.3-26.7% (p < 0.001), admission to special care nursery 16.7-25.0% (p < 0.001), and neonatal hypoglycaemia (<2.6 mmol/L) 6.0-27.0% (p < 0.001). Many women with T1D and T2D had limited pregnancy planning including first trimester hyperglycaemia (HbA1c > 6.5% (48 mmol/mol)), 78.4% and 54.6%, respectively (p < 0.001). CONCLUSION: Management of maternal hyperglycaemia and pregnancy outcomes varied significantly. The maintenance and extension of this benchmarking service provides opportunities to identify policy and clinical approaches to improve pregnancy outcomes among women with hyperglycaemia in pregnancy.

Aspirin and pre-eclampsia prevention in women with pre-existing diabetes: a retrospective study.

BACKGROUND: Aspirin is routinely prescribed in high-risk pregnancies to prevent pre-eclampsia; however, there is a paucity of data in women with pre-existing diabetes. AIMS: To assess the efficacy and safety of aspirin in women with pre-existing diabetes in preventing pre-eclampsia. METHODS: A retrospective review of women with pre-existing diabetes who attended antenatal clinics in a tertiary referral hospital between 2013 and 2019 was conducted. Cases were those receiving aspirin prior to 16 weeks, with pre-eclampsia as the primary outcome. The relationship between early pregnancy glycaemic control and pre-eclampsia was also assessed. RESULTS: Of the 164 women included in the study, 45 received aspirin. There were no differences in pre-eclampsia (odds ratio (OR) 0.9 (0.3-3.0), P = 0.924) or any other measure of placental insufficiency (OR 1.7 (0.7-4.3), P = 0.243) between the aspirin and control groups after adjusting for baseline differences. Aspirin therapy was associated with an increased risk of postpartum haemorrhage (PPH) (OR 3.1 (1.1-9.1), P = 0.041). The incidence of pre-eclampsia increased stepwise according to early pregnancy HbA1c subgroups of ≤6.0% (n = 47), 6.1-7.5% (n = 57) and > 7.5% (n = 39), with rates of 0, 12.3 and 20.5% (P = 0.007) respectively. CONCLUSIONS: The aspirin group had a higher baseline risk of pre-eclampsia and placental insufficiency, therefore the absence of difference between the groups favoured the efficacy of aspirin. PPH was highlighted as a potential complication of therapy, and early pregnancy HbA1c as a novel risk stratification tool for pre-eclampsia in women with pre-existing diabetes.

A 'Speed-Dating' Model of Wound Care? Rapid, High-Volume Assessment of Patients With Diabetes in a Multidisciplinary Foot Wound Clinic.

BACKGROUND: Diabetes is a major risk factor for foot ulceration and leg amputation, but the effect of intensive glycaemic control on wound healing is unknown. While an interdisciplinary approach has been shown to be important in the management of diabetic foot ulcer (DFU), there is no standardised definition of such an interdisciplinary team. OBJECTIVE: To investigate the role of an opportunistic, rapid-access, inter-disciplinary model of diabetes care at a foot wound clinic. METHODS: A retrospective case-control study of patients with DFUs attending a diabetes foot wound clinic over a 6-month period. Outcomes in patients who were seen by a rapid-access interdisciplinary team (RAIT) consisting of an endocrinologist, diabetes educator and dietician during the standard wound care those who were not seen by this team were compared. RESULTS: Fifty-five patients were seen by the RAIT and 64 control patients were not seen by this team during their attendance of a diabetes foot wound clinic. Patients in the intervention group had non-significantly higher baseline HbA1c and a significantly larger proportion were active cigarette smokers. Both groups achieved comparable reduction in the total number of DFUs per patient (p=0.971). Patients in the intervention group had a 60.1% reduction in wound size compared to 52.4% reduction in control group (p=0.526). CONCLUSION: Our study shows that the use of a rapid-access interdisciplinary team to assess and manage patients' diabetes in a foot wound clinic is feasible. Patients with higher-risk diabetes foot wounds exposed to RAIT had comparable wound healing outcomes to lower risk patients.

Urinary and Serum Angiogenic Markers in Women With Preexisting Diabetes During Pregnancy and Their Role in Preeclampsia Prediction.

OBJECTIVE: To determine the correlation between urinary and serum placental growth factor (PlGF) and investigate the predictive value as pregnancy progresses of urinary PlGF compared with serum PlGF, soluble fms-like tyrosine kinase 1 (sFLT-1), and the sFLT-1-to-PlGF ratio for the outcome of preeclampsia in women with preexisting diabetes. RESEARCH DESIGN AND METHODS: A multicenter prospective cohort study was conducted of 158 women with preexisting insulin-requiring diabetes (41 with type 1 and 117 with type 2). Urinary PlGF and serum PlGF, sFLT-1, and the sFLT-1-to-PlGF ratio were assessed four times (14, 24, 30, and 36 weeks' gestation), and the association with the outcome of preeclampsia was investigated. RESULTS: A correlation between urinary and serum PlGF was demonstrated from 24 weeks' gestation onward (P < 0.001). At all time points, those who developed preeclampsia had lower serum PlGF levels (P < 0.05), and receiver operating characteristic curves demonstrated that serum PlGF in this cohort performed better than the serum sFLT-1-to-PlGF ratio as a predictive test for preeclampsia. Preconception HbA1c ≥6.5% (48 mmol/mol) was an important discriminative predictor for preeclampsia (P = 0.01). CONCLUSIONS: This study prospectively describes the longitudinal changes in urinary PlGF alongside serum angiogenic markers throughout pregnancy in women with preexisting diabetes. We demonstrate correlation between urinary and serum PlGF and that in women with preexisting diabetes in pregnancy, serum PlGF is a better predictor of preeclampsia than the sFLT-1-to-PlGF ratio.

Microalbuminuria as an early predictor of preeclampsia in the pre-gestational diabetic population: A prospective cohort study.

OBJECTIVES: To determine if microalbuminuria can be used as a predictive marker of preeclampsia and adverse pregnancy and neonatal outcomes in women with pre-existing diabetes and to compare the prognostic utility of urinary albumin to creatinine ratio (uACR) and urinary protein to creatinine ratio (uPCR). STUDY DESIGN: Multicentre prospective cohort study. Antenatal Diabetes in Pregnancy clinics at three tertiary referral hospitals in Western Sydney, Australia. 158 women with pre-existing diabetes requiring insulin in pregnancy. A spot uPCR and uACR was performed in each trimester. Pregnancy and fetal outcomes were investigated using linear models and receiver-operating characteristic (ROC) curves. MAIN OUTCOME MEASURES: The primary outcome was preeclampsia (PE). Secondary outcomes investigated were other adverse pregnancy and neonatal outcomes. RESULTS: Increased levels of both uPCR and uACR in trimester 3 were associated with the occurrence of PE (p = 0.007, 0.010 respectively). In the 113 patients with normal pregnancy uPCR (<30 mg/mmol) in trimester 1, microalbuminuria was found to be predictive of PE (p = 0.01) and need for operative delivery (p = 0.03). CONCLUSIONS: In women with pre-existing diabetes, uPCR and uACR appear to have similar ability to diagnose PE, but microalbuminuria demonstrates prognostic ability at a much earlier gestation, prior to the onset of other signs or symptoms of PE. We therefore suggest that assessing microalbuminuria rather than overt proteinuria in trimester 1 provides prognostic information in women with pre-existing diabetes requiring insulin and should be used routinely to evaluate risk of PE in this high-risk cohort of women.

Causes of stillbirths in diabetic and gestational diabetes pregnancies at a NSW tertiary referral hospital.

BACKGROUND: Diabetes in pregnancy may result in stillbirth or neonatal death. AIM: This audit examined stillbirths of mothers with pre-existing diabetes in pregnancy (DIP) and gestational diabetes (GDM) to determine maternal and diabetic characteristics implicated in these deaths. MATERIALS AND METHODS: A retrospective cohort study was conducted to identify stillbirths occurring in diabetic pregnancies at Westmead Hospital during 2006-2017. Medical records were reviewed to obtain data relating to maternal factors, diabetes history, glycaemic control and cause of death. RESULTS: There were 37 women (seven with type 1 diabetes [T1DM], 11 with type 2 diabetes [T2DM] and 19 with GDM) who had 38 stillbirths. The leading cause of stillbirth was lethal congenital malformations in nine cases, followed by placental and umbilical abnormalities in six, intra-uterine growth restriction (IUGR) in six, and obstetric factors in four cases. Malformations were predominantly cardiovascular (n = 7), musculoskeletal (n = 5) and gastrointestinal (n = 4). There was no difference in the proportion of stillbirths related to malformations between the DIP and GDM groups (P = 0.22). In the pre-conception period or first trimester, all T1DM subjects and all but two T2DM subjects had HbA1c >7% or there was no measurement. HbA1c was >7% in 6/7 T1DM subjects and 7/11 T2DM subjects at some stage during the pregnancy. CONCLUSION: Stillbirth remains a problem in diabetic pregnancy in the 21st century. Lethal malformations, placental abnormalities and IUGR were the leading causes of stillbirth related to diabetes. Pre-conception counselling and planning to achieve better glycaemic control in pregnancy needs to be improved.

The Association of Falling Insulin Requirements With Maternal Biomarkers and Placental Dysfunction: A Prospective Study of Women With Preexisting Diabetes in Pregnancy.

OBJECTIVE: To investigate the association of falling insulin requirements (FIR) among women with preexisting diabetes with adverse obstetric outcomes and maternal biomarkers longitudinally in pregnancy. RESEARCH DESIGN AND METHODS: A multicenter prospective cohort study of 158 women (41 with type 1 diabetes and 117 with type 2 diabetes) was conducted. Women with FIR of ≥15% from the peak total daily dose after 20 weeks' gestation were considered case subjects (n = 32). The primary outcome was a composite of clinical markers of placental dysfunction (preeclampsia, small for gestational age [≤5th centile], stillbirth, premature delivery [<30 weeks], and placental abruption). Maternal circulating angiogenic markers (placental growth factor [PlGF] and soluble fms-like tyrosine kinase 1 [sFlt-1]), placental hormones (human placental lactogen, progesterone, and tumor necrosis factor-α), HbA1c, and creatinine were studied serially during pregnancy. RESULTS: FIR ≥15% were associated with an increased risk of the composite primary outcome (odds ratio [OR] 4.38 [95% CI 1.9-10.3]; P < 0.001), preeclampsia (OR 6.76 [95% CI 2.7-16.7]; P < 0.001), and was more common among women with type 1 diabetes (36.6 vs. 14.5%; P = 0.002). Creatinine was modestly elevated among women with FIR ≥15%; however, there was no difference in HbA1c. The ratio of sFlt-1 to PlGF was significantly higher among women with FIR at 25, 30, and 36 weeks, with differences maintained in the subgroup that developed preeclampsia. There was no difference in placental hormones between the groups. CONCLUSIONS: This is the first prospective study to associate FIR with altered expression of placental antiangiogenic factors and preeclampsia. FIR are an important clinical sign, among women with preexisting diabetes, that should alert the clinician to investigate underlying placental dysfunction.

Effect of pregnancy on insulin requirements differs between type 1 and type 2 diabetes: A cohort study of 222 pregnancies.

BACKGROUND: Knowledge about expected insulin requirements during pregnancy, in women with pre-existing diabetes may assist clinicians to effectively respond to gestation-specific changes in glycemic pattern. Few studies have examined differences between type 1 (T1DM) and type 2 diabetes (T2DM). AIMS: To compare patterns of insulin requirements in pregnancy for women with pre-existing T1DM and T2DM. MATERIAL AND METHODS: A retrospective cohort study of 222 pregnancies was conducted in women with pre-existing diabetes, (67 with T1DM, 155 with T2DM). Total daily insulin dose (TID) at the end of each trimester, recorded as units and units per kilogram (median, 25th-75th percentile) as well as percentage increase in insulin dose per trimester were compared. RESULTS: Women with T1DM had higher insulin requirements in the first two trimesters than those with T2DM (0.69 (0.58-0.85) vs 0.36 (0.0-0.7) units/kg in first trimester; 0.80 (0.62-0.95) vs 0.61 (0.27-0.95) units/kg, P < 0.005) in second trimester), but requirements in late pregnancy were similar (0.97 (0.69-1.29) vs 0.95 (0.53-1.32) units/kg, P = 0.54). Women with T2DM needed much greater increases in insulin per trimester compared to T1DM (P < 0.001). Women with T1DM had a net fall in insulin requirements (3.7% in the first trimester and 4.1% in the late third trimester) while those with T2DM did not. CONCLUSIONS: This is the largest comparison study of insulin requirements in women with pre-existing diabetes, highlighting important trimester-specific differences between T1DM and T2DM to guide insulin titration during pregnancy. Our findings suggest a differential effect of pregnancy-mediated insulin resistance by type of diabetes.

Pre-existing diabetes in pregnancy.

The incidence of type 1 and type 2 diabetes amongst women of reproductive age is increasing worldwide. Despite recent advances in treatment options for diabetes outside of pregnancy, women still have a significantly increased risk of adverse obstetric outcomes including perinatal death and congenital malformation, compared to the non-diabetic population. An understanding of the physiological changes during pregnancy, management, early detection and prevention of complications and pre-pregnancy care, specific to women with pre-existing diabetes, is important in improving health outcomes in this growing group of women. This review particularly focuses on areas where there have been recent developments or controversy.

Pre-existing diabetes in pregnancy.

The incidence of type 1 and type 2 diabetes amongst women of reproductive age is increasing worldwide. Despite recent advances in treatment options for diabetes outside of pregnancy, women still have a significantly increased risk of adverse obstetric outcomes including perinatal death and congenital malformation, compared to the non-diabetic population. An understanding of the physiological changes during pregnancy, management, early detection and prevention of complications and pre-pregnancy care, specific to women with pre-existing diabetes, is important in improving health outcomes in this growing group of women. This review particularly focuses on areas where there have been recent developments or controversy.

Increase in body mass index during pregnancy and risk of gestational diabetes.

We recorded gestational weight gain (GWG) and change in body mass index (BMI) at 28 weeks gestation in 343 vs. 339 women with and without gestational diabetes (GDM). GDM was associated with a greater increment in BMI, but not with increased GWG in kilograms.

Falling insulin requirements are associated with adverse obstetric outcomes in women with preexisting diabetes.

OBJECTIVE: To investigate the clinical significance of falling insulin requirements in women with preexisting or overt diabetes in pregnancy. RESEARCH DESIGN AND METHODS: A retrospective review of 139 pregnancies was conducted in women, with preexisting diabetes, delivering between January 2010 and January 2013. Women with falling insulin requirements of 15% or more from the peak total daily dose in late pregnancy were considered case subjects (n = 35). The primary outcome consisted of a composite of clinical markers of placental dysfunction, including preeclampsia, small for gestational age (SGA, ≤5th percentile for gestational age), stillbirth (>20 weeks), and premature delivery (≤30 weeks). RESULTS: A total of 25.2% of women had >15% fall in insulin requirements with nulliparity as the only predictor at baseline (odds ratio [OR] 2.5 [95% CI 1.1-5.7], P = 0.03). Falling insulin requirements were associated with an increased risk of preeclampsia (OR 3.5 [1.1-10.7], P < 0.05) and the composite of clinical markers of placental dysfunction (4.4 [1.73-11.26], P = 0.002). Although falling insulin requirements were associated with higher rates of SGA (3.4 [1.0-11.3], P = 0.048), they were not associated with other adverse neonatal outcomes. However, there was a higher incidence of neonatal intensive care unit admission (15.5 [3.1-77.6], P = 0.001) and earlier delivery in this group (median 37.7 weeks [IQR 34.3-38.4] vs. 38.3 weeks [37.4-38.9], P = 0.014). CONCLUSIONS: Falling insulin requirements, in women with preexisting diabetes, are associated with an increased risk of complications related to placental dysfunction. Further prospective studies are needed to guide clinical management.