Maria Grazia Dalfrà

Analysis of outcome of pregnancy in type 1 diabetics treated with insulin pump or conventional insulin therapy

Abstract.We evaluated the outcome of pregnancies followed between 1990 and 2000 in 93 women with type 1 diabetes, treated with conventional intensive insulin therapy (n=68) or continuous subcutaneous insulin infusion (n=25). We evaluated metabolic control (fasting and 1-hour post-prandial plasma glucose and HbA1c levels), spontaneous or induced abortions, time and mode of delivery, maternal outcome (pregnancy-induced hypertension, preeclampsia, placental insufficiency, hydramnios, hypoglycemic coma, ketoacidosis) and fetal outcome (weight, hypoglycemia, hypocalcemia, hyperbilirubinemia, fetal distress, asphyxia, hyaline membrane disease, polycythemia, shoulder dystocia, malformations). Patients treated with insulin pump more frequently had background retinopathy and clinical neuropathy. No significant differences were observed between the two groups in metabolic control and maternal outcome. Glycemic control, non-optimal in the prepregnancy state, improved significantly during pregnancy, as shown by the progressive reduction in HbA1c levels. As regards fetal outcome, no differences were observed between the two groups in morbidity and especially in malformation rate. Patients with malformed babies did not have optimal metabolic control at conception. Thus, maternal and perinatal outcomes were comparable in patients treated with insulin pump and continuous subcutaneous insulin therapy, and depended on metabolic control. In patients in higher White’s class and with more unstable glycemia, we achieved metabolic control and outcomes comparable with those of women of lower White’s class and more stable glycemic values using the insulin pump. Our data suggest that insulin pump therapy is useful in problematic, complicated cases of women who want a baby.

The effect of telemedicine on outcome and quality of life in pregnant women with diabetes

We evaluated the effect of a telemedicine system on maternal and fetal outcome in women with diabetes. A total of 276 pregnant women were enrolled in the study. Women were sequentially assigned to a telemedicine or a control group. There were 88 women with gestational diabetes in the telemedicine group and 115 in the control group; there were 17 women with type 1 diabetes in the telemedicine group and 15 in the control group. Women in telemedicine groups were asked to submit their blood glucose data every week, and had a medical examination at the diabetes clinic once a month. Women in the control groups had a medical examination every two weeks. Subjective outcomes were investigated using the following questionnaires: CES-D for depression, SF-36 for health-related quality of life (QoL), Stress and Distress for the impact of diabetes. Clinical variables and pregnancy outcomes were no different between the two telemedicine groups, whereas women with gestational diabetes in the telemedicine group had a better metabolic control in the 3rd trimester and a lower rate of caesarean sections and macrosomia. As for QoL, women in the telemedicine groups showed lower levels of frustration and concerns about their diabetes, and a better acceptance of their diabetic condition. A questionnaire on the use of the telemedicine system showed a high degree of acceptance (85%). Both telemedicine groups had fewer check-ups at the diabetes clinics. The use of a telemedicine system for glucose monitoring improved pregnancy outcome in women with gestational diabetes and improved QoL in all diabetic pregnancies.

Pregnancy and foetal outcome after bariatric surgery: a review of recent studies

It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.

Diabetes related autoimmunity in gestational diabetes mellitus: is it important?

Some GDM women show autoantibody positivity during and after pregnancy and pancreatic autoantibodies can appear for the first time in some patients after delivery. Autoantibody positivity is often accompanied by a high frequency of DR3 and DR4 alleles, which are classically related to the development of type 1 diabetes and, although not all studies agree on this point, by an immunological imbalance expressed by the behaviour of the lymphocyte subpopulation, which can be seen as diabetic anomalies overlapping with the immunological changes that occur during pregnancy. It is worth emphasizing that such patients may develop classical type 1 diabetes during and/or after their pregnancy or they may evolve, often some years after their pregnancy, into cases of latent autoimmune diabetes of adulthood (LADA). Autoimmune GDM accounts for a relatively small number of cases (about 10% of all GDM) but the risk of these women developing type 1 diabetes or LADA is very high, so these patients must be identified in order to prevent the severe maternal and fetal complications of type 1 diabetes developing in pregnancy, or its acute onset afterwards. Since women with autoimmune GDM must be considered at high risk of developing type 1 diabetes in any of its clinical forms, these women should be regarded as future candidates for the immunomodulatory strategies used in type 1 diabetes.

Glucose Variability in Diabetic Pregnancy

BACKGROUND Fetal overgrowth is the most important complication of gestational (GDM) and pregestational diabetes mellitus. METHODS We correlated maternal glucose profiles, as detected by continuous glucose monitoring (CGM), with fetal growth parameters for 80 pregnant women (32 with type 1 diabetes, 31 with GDM, and 17 healthy controls). Glucose profiles were monitored in the first, second, and third trimesters of pregnancy for type 1 diabetes women and in the second and third trimesters for GDM women and controls. To analyze glycemic variability, we considered the mean amplitude of glycemic excursion, mean glycemia, the continuous overlapping net glycemic action (CONGA), the SD, the High Blood Glucose Index (HBGI), the Low Blood Glucose Index, and the interquartile range (IQR). RESULTS Mean age was the same for the three groups. Prepregnancy body mass index was higher for the women with diabetes (GDM and type 1) than for controls. The newborns mean birth weight and ponderal index were higher, although not significantly so, for the women with diabetes than for controls. For the type 1 diabetes patients, ponderal index correlated with the HBGI in the first trimester, CONGA1 and IQR in the second, and mean glycemia and SD in the third. For GDM patients, ponderal index correlated with mean glycemia and the HBGI in the second trimester. CONCLUSIONS Fetal exposure to glycemic variability and hyperglycemia seems to be important in determining fetal overgrowth in pregnant women with diabetes. Optimal glucose control and less glucose variability are needed as early as possible in both type 1 diabetes and GDM patients to ensure normal fetal growth.

Effect of physical activity and/or healthy eating on GDM risk: The DALI Lifestyle Study

Context Lifestyle approaches for preventing gestational diabetes mellitus (GDM) have produced mixed results. Objective The aim of the present study was to compare the effectiveness of 3 lifestyle interventions [healthy eating (HE), physical activity (PA), and both HE and PA (HE+PA)] with usual care (UC) in reducing GDM risk. Design The present study was a multicenter randomized controlled trial conducted from 2012 to 2014 [the DALI (vitamin D and lifestyle intervention for GDM prevention) lifestyle study]. Setting The study occurred at antenatal clinics across 11 centers in 9 European countries. Patients Consecutive pregnant women at <20 weeks of gestation with a body mass index (BMI) of ≥29 kg/m2 and without GDM using the International Association of Diabetes and Pregnancy Study Group criteria (n = 436). For the intervention, women were randomized, stratified by site, to UC, HE, PA, or HE+PA. The women received 5 face-to-face and ≤4 telephone coaching sessions using the principles of motivational interviewing. A gestational weight gain (GWG) <5 kg was targeted. The coaches received standardized training and an intervention toolkit tailored to their culture and language. Main Outcome Measures The endpoints were the GWG at 35 to 37 weeks and the fasting glucose and insulin sensitivity [homeostasis model assessment insulin resistance (HOMA-IR)] at 24 to 28 weeks. Results We randomized 108 women to HE+PA, 113 to HE, 110 to PA, and 105 to UC. In the HE+PA group, but not HE or PA alone, women achieved substantially less GWG than did the controls (UC) by 35 to 37 weeks (-2.02; 95% confidence interval, -3.58 to -0.46 kg). Despite this reduction, no improvements were seen in fasting or postload glucose levels, insulin concentrations, or HOMA-IR. The birthweights and large and small for gestational age rates were similar. Conclusions The combined HE+PA intervention was able to limit GWG but did not reduce fasting glycemia. Thus, lifestyle changes alone are unlikely to prevent GDM among women with a BMI of ≥29 kg/m2.

Pregnancy complicated by type 2 diabetes: An emerging problem

The prevalence of type 2 diabetes in pregnancy has increased everywhere in recent years. A number of studies have suggested that adverse maternal and fetal outcomes in these women have approached the figures for type 1 diabetic pregnancies. A low rate of planned pregnancies, suboptimal metabolic control and obesity have emerged as significant factors contributing towards poor outcome in these women, so efforts should be made to monitor these patients more carefully in order to improve this situation.

IADPSG and WHO 2013 Gestational Diabetes Mellitus Criteria Identify Obese Women With Marked Insulin Resistance in Early Pregnancy

Implementation of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and the World Health Organization 2013 (WHO 2013) recommendations leads to an increased prevalence of gestational diabetes mellitus (GDM) due to more stringent criteria and early screening of women at high risk for diabetes in pregnancy (DIP) (1,2). IADPSG members now recommend that their GDM criteria should not be used in early pregnancy but have not provided alternative criteria (3). We have compared the characteristics of overweight/obese women early in pregnancy, with and without GDM using the new criteria, to assess whether those testing positive are metabolically distinct. Pregnant women with a BMI ≥29.0 kg/m2 underwent a 75-g oral glucose tolerance test in early pregnancy as part of enrollment into the DALI (Vitamin D And Lifestyle Intervention for GDM prevention) pilot and lifestyle Pan-European multicenter trials (4). GDM and DIP were diagnosed using WHO 2013 criteria. A high rate of GDM (237/1,035 or 22.9%: DIP 0.5%; total hyperglycemia in early pregnancy 23.4%) was found at a …

Pregnancy complicated by diabetes: what is the best level of HbA1c for conception?

To reduce the congenital malformations that occur in pregnancies complicated by diabetes, it is essential to achieve and maintain a good metabolic control before conception. In this context, measuring HbA1c is considered as the gold standard for monitoring metabolic control in diabetes and various different HbA1c levels have been recommended as optimal in the preconception period for diabetic women planning a pregnancy. An analysis of key studies published on this issue until now clearly shows that HbA1c levels correlate closely with the occurrence of congenital malformations and other neonatal complications characteristic of pregnant diabetic women. HbA1c is therefore one of the key markers to use in monitoring metabolic control, and the most reasonable approach would seem to be to use a standardized measurement method and aim for HbA1c levels resembling normal values as closely as possible, with a view to preventing episodes of hypoglycemia.

Pregnancy outcome in immigrant women with gestational diabetes mellitus

Recent studies show adverse outcomes of pregnancy among immigrant women from countries with high diabetes rates. We compared maternal and fetal outcomes in immigrant and Italian women with gestational diabetes mellitus (GDM) followed up at our center. Maternal characteristics considered were age, pre-pregnancy body mass index (BMI), HbA1c, frequency of insulin treatment, timing and mode of delivery, and hypertensive disorders; and, for fetal outcome, infants large or small for gestational age, and fetal complications. Pre-pregnancy BMI and HbA1c were higher in immigrant GDM women than in Italians, and more of them were on insulin. No differences in maternal outcome emerged between the two groups. More large for gestational age (LGA) babies were born to immigrant women than to Italians, but no other differences emerged. Apart from newborn LGA, maternal and fetal outcomes were comparable in our immigrant and Italian GDM women. Immigrant GDM women have favourable outcomes if given access to health care and language and cultural barriers are removed.