Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial

Murphy, Helen; Rayman, Gerry; Lewis, Karen; Kelly, Susan; Johal, Balroop; Duffield, Katherine; Fowler, Duncan; Campbell, Peter J.; Temple, Rosemary

doi:10.1136/bmj.a1680

Cited by 308 publications

(240 citation statements)

References 34 publications

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“…Increased use of continuous glucose monitoring has been shown to improve second and third trimester glycaemic control in type 1 diabetic patients [37]. Our results indicate that a more intensive therapeutic approach, including timely increments in insulin dosages, should be adopted in type 1 diabetic patients throughout pregnancy.…”

Section: Discussionmentioning

confidence: 92%

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989–2008

et al. 2012

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Aims/hypothesis Our objective was to examine the trends in prepregnancy BMI and glycaemic control among Finnish type 1 diabetic patients and their relation to delivery mode and perinatal outcome. Methods We analysed the obstetric records of 881 type 1 diabetic women with a singleton childbirth during 1989-2008. Maternal prepregnancy weight and height were obtained from the maternity cards, where they are recorded as reported by the mother. Results Maternal BMI increased significantly during 1989-2008 (p<0.001). The mean HbA 1c in the first trimester remained unchanged, but the midpregnancy and the last HbA 1c before delivery increased (p00.009 and 0.005, respectively). Elective Caesarean sections (CS) decreased (p for trend <0.001), while emergency CS increased (p for trend <0.001). The mean umbilical artery (UA) pH decreased in vaginal deliveries (p for trend <0.001). The frequency of UA pH <7.15 and <7.05 increased (p for trend <0.001 and 0.008, respectively). The macrosomia rate remained at 32-40%. Neonatal intensive care unit (NICU) admissions increased (p for trend 0.03) and neonatal hypoglycaemia frequency decreased (p for trend 0.001). In multiple logistic regression analysis, maternal BMI was associated with macrosomia and NICU admission. The last HbA 1c value before delivery was associated with delivery before 37 weeks' gestation, UA pH <7.15, 1 min Apgar score <7, macrosomia, NICU admission and neonatal hypoglycaemia. Conclusions/interpretation Self-reported pregestational BMI has increased and glycaemic control during the second half of pregnancy has deteriorated. Poor glycaemic control seems to be associated with the observed increases in adverse obstetric and perinatal outcomes.

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Section: Discussionmentioning

confidence: 92%

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989–2008

et al. 2012

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“…Our measure of glycaemia was limited to HbA 1c ; this has excellent validity as an estimate of average blood glucose but does not provide information on glycaemic excursions, which may be an important driver for macrosomia [17,25,26]. Moreover, we did not have 100% completeness for peri-conception and trimester-specific HbA 1c measurements.…”

Section: Discussionmentioning

confidence: 99%

“…The increased risk of an LGA birth in women with diabetes is thought to be associated with poor glycaemic control, usually estimated by concentration of HbA 1c before or during pregnancy [5,11,16,17]. However, the evidence and the direction of the association, particularly in relation to pre-and post-conception glycaemic control, is inconsistent.…”

Section: Introductionmentioning

confidence: 96%

HbA1c and birthweight in women with pre-conception type 1 and type 2 diabetes: a population-based cohort study

et al. 2012

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Aims/hypothesis To investigate clinical and sociodemographic predictors of birthweight in singletons born to women with type 1 or type 2 diabetes. Methods Normally formed singleton live births and intrapartum stillbirths, born to women with pre-conception diabetes during 1996-2008, were identified from the population-based Northern Diabetes in Pregnancy Survey (n01,505). Associations between potential predictors and birthweight were analysed by multiple regression. Results Potentially modifiable independent predictors of increase in birthweight were pre-pregnancy care (adjusted regression coefficient [b]087.1 g; 95% CI 12.9, 161.3), increasing third-trimester HbA 1c ≤7% (53 mmol/mol) (b0310.5 g per 1% [11 mmol/mol]; 95% CI 246.3, 374.7) and increasing maternal BMI (b09.5 g per 1 kg/m 2 ; 95% CI 3.5, 15.5). Smoking during pregnancy (b0−145.1 g; 95% CI −231.4, −58.8), later gestation at first antenatal visit (b0−15.0 g; 95% CI −26.9, −3.0) and higher peri-conception HbA 1c (b0−48.2 g; 95% CI −68.8, −27.6) were independently associated with birthweight reduction. Pre-pregnancy nephropathy (b 0−282.7 g; 95% CI −461.8, −103.6) and retinopathy (b0−175.5 g; 95% CI −269.9, −81.0) were independent non-modifiable predictors of reduced birthweight, while greater maternal height was a non-modifiable predictor of increasing birthweight (b017.8 g; 95% CI 12.3, 23.2). Other predictors of birthweight increase were male sex, multiparity and increasing gestational age at delivery. Type or duration of diabetes, socioeconomic status and ethnicity were not associated with continuous birthweight. Conclusions/interpretation Poor glycaemic control before and throughout pregnancy is associated with abnormal fetal growth, with increasing peri-conception HbA 1c predicting weight reduction and increasing third-trimester HbA 1c predicting increased birthweight. Women with microvascular complications of diabetes may require increased surveillance to detect fetal growth restriction.

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“…Testing 1 h after meals may capture peak postprandial glucose, in some women for some meals, but fails to capture the complexity of total carbohydrate absorption between different meals or different women. In practice, continuous glucose monitoring or repeated postprandial testing may be required for optimal insulin dose adjustment [36].…”

Section: Discussionmentioning

confidence: 99%

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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Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial

Cited by 308 publications

References 34 publications

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989–2008

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989–2008

HbA1c and birthweight in women with pre-conception type 1 and type 2 diabetes: a population-based cohort study

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

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