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The CGMS is an accurate tool for additional glucose monitoring in pregnant women with type 1 diabetes mellitus.

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In women with type 1 diabetes, extreme growth of the fetus starts early in pregnancy and is likely caused by increased maternal glucose levels. Further investigation is needed to see whether early tight glycemic control will reduce the number of extreme LGA infants.

Aims/hypothesis: Pregnancies of women with type 1 diabetes mellitus are associated with maternal and perinatal complications. These complication rates remain elevated despite achievement of the treatment goals described in the widely used guidelines of the American Diabetes Association (i.e. HbA 1 c level ≤7.0%). Against this background, we sought to answer two questions: (1) are HbA 1 c levels within 1% above normal appropriate in pregnant women with type 1 diabetes or should treatment be aimed at normal HbA 1 c levels; and (2) how many selfmonitored blood glucose (SMBG) levels are needed per day to obtain an adequate image of glycaemic control in pregnant women with type 1 diabetes? Materials and methods: We asked 43 pregnant women with type 1 diabetes to use the Continuous Glucose Monitoring System (CGMS) once in each trimester of pregnancy, while continuing their SMBG measurements. Glucose levels measured with the CGMS were compared between patients with HbA 1 c levels of 4.0-6.0%, 6.0-7.0% and >7.0%. Self-monitored glucose levels and those measured with CGMS were compared between patients with four or five, six to nine and ten or more SMBG determinations daily. Results: In patients with HbA 1 c levels ≤6.0%, the glucose levels obtained by CGMS were significantly better than in patients with HbA 1 c levels >6.0%. In women with HbA 1 c levels 6.0-7.0% and >7.0%, these levels did not differ. The detection rate of hyper-and hypoglycaemic episodes was significantly higher in patients with ten or more SMBG determinations daily than in patients with fewer than ten. Conclusions/interpretation: Treatment of diabetes in pregnant women should be aimed at achieving HbA 1 c levels within the normal range, i.e. ≤6.0%. A minimum of ten SMBG determinations daily is necessary to obtain adequate information of all daily glucose fluctuations.

Objective To observe day-to-day variability in glucose levels in pregnant women with Type 1 diabetes using the Continuous Glucose Monitoring System (CGMS) and to assess the usefulness of continuous glucose measurements for adjustment of insulin treatment. Design A prospective observational study.Setting The obstetrical outpatient clinic of the University Medical Centre Utrecht.Population Pregnant women with Type 1 diabetes mellitus.Methods Thirty-one pregnant women with Type 1 diabetes used the CGMS for two consecutive days. Patients were classified in two groups (high vs low day-to-day variability) based on visual inspection of the glucose excursions. The relationship between day-to-day variability and the variables HbA 1c , maternal age and body mass index (BMI), duration of diabetes, number of self-monitored blood glucose levels, number of insulin injections, gestational age, nutrition, physical activity, White classification, living with children and method of insulin administration was determined. The two days of the first 20 CGMS measurements were separated and four physicians were asked to give recommendations on treatment adjustment for each separate day. Main outcome measures Mean absolute difference (MAD) was calculated for each patient as measure of dayto-day variability. Results Seventeen patients (55%) were classified as having low (MAD 0.92-2.33 mmol/L) and 14 (45%) as having high day-to-day variability (MAD 2.41 -6.12 mmol/L). Of the variables measured, only the relation between MAD and HbA 1c was significant (r ¼ 0.58, P ¼ 0.001). The difference in recommendation on treatment adjustment between the days of the CGMS measurement ranged from 29% to 48%. This percentage was significantly higher in the high day-to-day variability group (48 vs 33%, P ¼ 0.01). Conclusion Day-to-day glucose variability is high and the treatment of pregnant women with Type 1 diabetes is a problem. Fine-tuning of insulin regimens based on two-day measurements with the CGMS is not advisable.

OBJECTIVE -Large-for-gestational-age (LGA) infants (birth weight Ն90th centile) are a continuing problem in pregnancies of women with type 1 diabetes. We used the continuous glucose monitoring system (CGMS) to assess the relationship between 24-h diurnal glucose profiles in all three trimesters of pregnancy and infant birth weight.RESEARCH DESIGN AND METHODS -Twenty-nine pregnant women with type 1 diabetes used the CGMS during each trimester of pregnancy. The glucose profiles of the women with a normal-weight infant or an LGA infant were compared.RESULTS -Of the women with type 1 diabetes, 48% gave birth to an LGA infant. Fifty percent of these infants were already large for dates on ultrasound at Ͻ30 weeks of gestation (early LGA), and all these infants had a birth weight Ն97.7th centile. The diurnal glucose profiles show that the mothers of early LGA infants had elevated glucose levels for most of the day during the second trimester (P Ͻ 0.05). The median 24-h glucose level was significantly higher in women who gave birth to early LGA infants in all three trimesters of pregnancy (6.7, 8.3, and 6.5 mmol/l for the first, second, and third trimesters, respectively). Within the group of women with early LGA infants, the second trimester median glucose level was significantly higher than that in the first and third trimester (P Ͻ 0.05).CONCLUSIONS -In women with type 1 diabetes, extreme growth of the fetus starts early in pregnancy and is likely caused by increased maternal glucose levels. Further investigation is needed to see whether early tight glycemic control will reduce the number of extreme LGA infants. Diabetes Care 30:1069 -1074, 2007T reatment of pregnant women with type 1 diabetes is aimed at achieving a pregnancy outcome that approximates that of nondiabetic women (1). Recent studies have shown that this target is far from being reached despite modern methods of treatment (2-6) and despite the maintenance of A1C levels within the limits advised by international guidelines (2,7).The birth of large-for-gestational-age (LGA) infants (birth weight Ն90th centile) is the most frequent of the complications seen in pregnancies of women with type 1 diabetes (2)(3)(4)(5)(6)8,9). It is associated with increased morbidity of both mother and child (10 -12). It has been shown that the LGA infant rate is positively related to glycemic control (13-16). Discrepancy, however, exists concerning the trimester of pregnancy in which tight glucose regulation is considered the most important. Page et al. (14) conclude that the incidence of macrosomia may be reduced by tighter control of diabetes at conception and during the first trimester, while two others studies show that second and third trimester glucose values are related to neonatal morbidity (13,15). A more recent study has shown that only second trimester glucose levels are related to perinatal outcome (16). An obstacle in the existing studies is that glycemic control was expressed as the mean of six to eight selfmonitored blood glucose levels a day. It is not likely...