Insulin Dosing, Glycemic Control, and Perinatal Outcomes in Pregnancies Complicated by Type-2 Diabetes

Abstract

Objective This study aimed to evaluate the prevalence of severe insulin resistance (insulin requirements ≥2 units/kg) at delivery and the relationship between severe insulin resistance, glycemic control, and adverse perinatal outcomes in pregnant women with type-2 diabetes mellitus. Study Design This is a retrospective cohort study of women with type-2 diabetes mellitus who delivered between January 2015 and December 2017 at a tertiary academic medical center. Maternal demographic information, self-monitored blood sugars, and insulin doses were abstracted from the medical record. Multivariable logistic regression was used to identify maternal baseline characteristics associated with severe insulin resistance at delivery. Results Overall 72/160 (45%) of women had severe insulin resistance. Women in the severe insulin resistance group demonstrated evidence of suboptimal glycemic control as evidenced by higher mean hemoglobin A1c (HbA1c) values (7.2 [ ± 1.1] vs. 6.6 [ ± 1.3%], p = 0.003), higher mean fasting (104.0 [ ± 17.4] vs. 95.2 [ ± 11.7 mg/dL], p < 0.001) and postprandial glucose values (132.4 [ ± 17.2] vs. 121.9 [ ± 16.9 mg/dL]), p < 0.001), and a higher percentage of total glucose values that were elevated above targets (37.7 [95% confidence interval (CI): 26.8–50] vs. 25.6 [95% CI: 13.3–41.3%], p < 0.001). Maternal HbA1c ≥6.5% and insulin use prior to pregnancy were associated with a higher prevalence of severe insulin resistance, while Hispanic ethnicity and non-White race were associated with a lower prevalence of severe insulin resistance. The rates of adverse perinatal outcomes including large for gestational age (LGA) birth weight, cesarean delivery, and hypertensive disorders of pregnancy did not differ between groups. Conclusion Severe insulin resistance is common among pregnant women with type-2 diabetes, and it is associated with suboptimal glycemic control. Future studies are necessary to develop strategies to identify women with severe insulin resistance early in pregnancy and facilitate adequate insulin dosing. Key Points

Drug-related problems in hypertension and gestational diabetes mellitus: A hospital cohort

“…Glycemic control through insulin administration is the treatment of first choice. The Brazilian guidelines, adopted by the evaluated institution, recommend the initial dose of NPH insulin 0.3 IU/kg divided into two administrations [22], but other authors recommend doses between 0.7-2.0 IU/kg for initial glycemic control [23][24][25]. Although initial insulin doses are commonly selected based on weight, Nadeau et al [25] suggest that baseline blood glucose may be a more relevant parameter since placental hormones induce a more resilient picture.…”

Pregnancy and Type 2 Diabetes: Unmet Goals

“…Even if T2D pregnant women show low levels of HbA1c during pregnancy, only half of these pregnancies meet the recommended levels of HbA1c and glycemia [16,29,30]. The physiologic insulin resistance of pregnancy is amplified by obesity, which often characterizes T2D patients [31,32]. To evaluate the frequency of insulin resistance and its possible correlation with glycemic control and pregnancy outcomes in T2D pregnant women, self-monitoring blood glucose levels, insulin dosage, and pregnancy outcomes were recorded in 160 T2D pregnant women (all insulin treated).…”

“…The frequency of obesity complicating T2D pregnancy was high in most studies examined. Obesity worsens the physiological insulin resistance characteristic of pregnancy and the insulin resistance typical of T2D [31,32,36,37]. This amplifies low-grade inflammation of the adipose tissue and the secretion of inflammatory cytokines.…”

Effect of Methionine Addition to Soybean Meal Instead of Protein Concentrate in the Finisher Ration of Broiler

“…Also DM in mothers young and the incidence of undetected elevated blood glucose surge are increasing (McIntyre et al, 2019). On the other hand, pregnancy developments, local surge level and placental hormone; counting estrogen; lactogen of placental; leptin; cortisol; progesterone, in addition growth hormone of the placental together support the insulin resistance state (Lafta et al, 2021;Nadeau et al, 2020& Barbou & Hernandez, 2018. GDM causes important short-and long-term health risks for the women, developing fetus, and children; this includes the high likelihood of subsequent maternal type 2 diabetes (T2DM), and possible adverse cardiometabolic phenotypes in the children (Johns et al, 2018).…”