Closed-Loop Insulin Delivery During Pregnancy Complicated by Type 1 Diabetes

Murphy, Helen; Elleri, Daniela; Allen, Janet M.; Harris, Julie; Simmons, David; Rayman, Gerry; Temple, Rosemary; Dunger, David B.; Haidar, Ahmad; Nodale, Marianna; Wilinska, Malgorzata E.; Hovorka, Roman

doi:10.2337/dc10-1796

Cited by 122 publications

(103 citation statements)

References 18 publications

(24 reference statements)

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“…However, it should be noted that there are typically no differences in the total insulin doses infused or plasma insulin concentrations during conventional CSII and closed-loop insulin delivery [22,23]. More work is needed to extend and validate our findings and to further evaluate the risks and benefits of earlier insulin administration in pregnancy in type 1 diabetes.…”

Section: Discussionmentioning

confidence: 99%

“…Glucose control Closed-loop insulin delivery was used to achieve stable and comparable glycaemic conditions prior to meal consumption and throughout both study visits [22]. Satisfactory glyacemic control was maintained with no (Fig.…”

Section: Resultsmentioning

confidence: 99%

“…Study protocol Ten pregnant women with type 1 diabetes were admitted to the Wellcome Trust clinical research facility (Cambridge, UK) for 24 h on two separate occasions during early pregnancy (12-16 weeks) and late gestation (28-32 weeks [22]. For women on CSII, their existing site was used, and for those previously on injection therapy, the insertion site was located on the inguinal region of the anterior abdominal wall.…”

Section: Methodsmentioning

confidence: 99%

“…Recent technological advances, in particular the accelerated development of closed-loop insulin delivery systems, have further highlighted the need for improved prandial algorithms [22,23]. Physiologically derived insulin algorithms would benefit from an accurate measurement of glucose turnover and insulin kinetics in pregnancy for women with type 1 diabetes.…”

Section: Introductionmentioning

confidence: 99%

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Pathophysiology of postprandial hyperglycaemia in women with type 1 diabetes during pregnancy

et al. 2011

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Aims/hypothesis Although maternal hyperglycaemia is associated with increased risk of adverse pregnancy outcome, the mechanisms of postprandial hyperglycaemia during pregnancy are poorly understood. We aimed to describe glucose turnover in pregnant women with type 1 diabetes, according to stage of gestation (early vs late gestation). Methods The rates of systemic glucose appearance (R a ) and glucose disposal (R d ) were measured in ten pregnant women with type 1 diabetes during early (12-16 weeks) and late (28-32 weeks) gestation. Women ate standardised meals-a starch-rich 80 g carbohydrate dinner and a sugarrich 60 g carbohydrate breakfast-and fasted between meals and overnight. Stable-label isotope tracers ([6,6-2 H 2 ]glucose and [U-13 C]glucose) were used to determine R a , R d and glucose bioavailability. Closed-loop insulin delivery maintained stable glycaemic conditions. Results There were no changes in fasting R a (10±2 vs 11±2 μmol kg -1 min -1 ; p=0.32) or fasting R d (11±2 vs 11±1 μmol kg -1 min -1 ; p=0.77) in early vs late gestation. There was increased hepatic insulin resistance (381±237 vs 540 ± 242 μmol kg -1 min -1 × pmol/l; p = 0.04) and decreased peripheral insulin sensitivity (0.09±0.04 vs 0.05±0.02 μmol kg -1 min -1 per pmol/l dinner, 0.11±0.05 vs 0.07±0.03 μmol kg -1 min -1 per pmol/l breakfast; p=0.002) in late gestation. It also took longer for insulin levels to reach maximal concentrations (49 [37-55]

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Section: Discussionmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Pathophysiology of postprandial hyperglycaemia in women with type 1 diabetes during pregnancy

et al. 2011

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“…All the data in the panel are from MPC studies-the green curve being from the same study by Russell and coauthors 16 shown in Figure 2A (repeated from Figure 1B) and the red and blue curves from studies performed by Hovorka and coauthors. 18,19 The first issue is how to compare two "closed-loop" algorithms in which one of the algorithms relies on a meal announcement with an open-loop meal bolus. The second, less obvious issue is how to decide which meal response is better-one that that goes up and down or one that remains flat.…”

Section: Review Of Available Clinical Datamentioning

confidence: 99%

Algorithms for a Closed-Loop Artificial Pancreas: The Case for Proportional-Integral-Derivative Control

Steil

2013

J Diabetes Sci Technol

105

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Abbreviation: (eCTR) enhanced control-to-range, (IQR) interquartile range, (MPC) model-predictive control, (PID) proportional integral derivative, (PD) pharmacodynamic, (PID IFB ) proportional integral derivative with insulin feedback, (PK) pharmacokinetic, (RLS) recursive least squares, (sCTR) standard control-to-range Journal of Diabetes Science and TechnologyVolume 7, Issue 6, November 2013 © Diabetes Technology Society AbstractClosed-loop insulin delivery continues to be one of most promising strategies for achieving near-normal control of blood glucose levels in individuals with diabetes. Of the many components that need to work well for the artificial pancreas to be advanced into routine use, the algorithm used to calculate insulin delivery has received a substantial amount of attention. Most of that attention has focused on the relative merits of proportionalintegral-derivative versus model-predictive control. A meta-analysis of the clinical data obtained in studies performed to date with these approaches is conducted here, with the objective of determining if there is a trend for one approach to be performing better than the other approach. Challenges associated with implementing each approach are reviewed with the objective of determining how these approaches might be improved. Results of the meta-analysis, which focused predominantly on the breakfast meal response, suggest that to date, the two approaches have performed similarly. However, uncontrolled variables among the various studies, and the possibility that future improvements could still be effected in either approach, limit the validity of this conclusion. It is suggested that a more detailed examination of the challenges associated with implementing each approach be conducted.

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Management of Preexisting Diabetes in Pregnancy

Alexopoulos

Blair

Peters

2019

JAMA

116

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Importance: The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, caesarian section, pre-term delivery, macrosomia and congenital defects. Approximately 0.9% of the 4,000,000 births in the United States are complicated by preexisting diabetes. Observations: Women with diabetes have increased risk for adverse maternal and neonatal outcomes and similar risks are present for either type 1 or type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies, and to minimize risk of congenital defects. Hemoglobin A1c goal at conception is <6.5% and during pregnancy is <6.0%. It is also critical to screen for and optimize comorbid illnesses such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Obese women should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully, as lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitor use can improve glycemic control and neonatal outcomes for women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore glucagon should be available and close contacts trained in its use. Low-dose aspirin is recommended soon after 12 weeks of gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy cannot be overstated, to allow for appropriate preconception planning. Conclusions and Relevance: Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk, but optimization of glycemic control, medication regimens and careful attention to comorbid conditions can help mitigate these risks, and ensure quality diabetes care before, during and after pregnancy.

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Closed-Loop Insulin Delivery During Pregnancy Complicated by Type 1 Diabetes

Cited by 122 publications

References 18 publications

Pathophysiology of postprandial hyperglycaemia in women with type 1 diabetes during pregnancy

Pathophysiology of postprandial hyperglycaemia in women with type 1 diabetes during pregnancy

Algorithms for a Closed-Loop Artificial Pancreas: The Case for Proportional-Integral-Derivative Control

Management of Preexisting Diabetes in Pregnancy

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