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This year's diabetes pregnancy manuscripts, three for each of type 1 diabetes (T1D), type 2 diabetes (T2D), and gestational diabetes mellitus (GDM), were chosen from over 3500 published articles. Data were collected on pregnant women with diabetes (any type) with DKA events (cases) and pregnant women with diabetes without DKA (controls) from 194 maternity units between April 2019 and September 2020. Another concerning finding is the prevalence of diabetic ketoacidosis (DKA) during pregnancy in all types of diabetes. Seventy DKA events (85%) occurred in women with T1D (incidence 16.6/100,000; 95% CI, 13.0-20.9), 5 DKA events (6%) in women with T2D (incidence 1.1/100,000; 95% CI, 0.4-2.5), and 7 (9%) in women diagnosed with GDM. [Extracted from the article]

Similarly, in late pregnancy, women with type 2 diabetes were more likely to have anxiety symptoms (31 vs 11%; I P i =0.002) and depressive symptoms (23 vs 4%; I P i =0.002) compared to women without diabetes. Compared to women without diabetes, those with type 2 diabetes were more likely to have both anxiety symptoms (36 vs 6%; I P i <0.001) and depressive symptoms (14 vs 2%; I P i =0.003) in early pregnancy. Conclusions While mean sensor glucose over 24 h and overnight were similar between IS-CGM and RT-CGM, time below range overnight was higher when assessed using IS-CGM compared to masked RT-CGM in early pregnancy. The manuscripts chosen for this yearbook address key controversies in the screening and detection of gestational diabetes mellitus (GDM), glycemic metrics using intermittent and continuous glucose monitoring (CGM) in type 1 diabetes and the theory of beta-cell regeneration. [Extracted from the article]

Results Case 1 presented at 4-weeks gestation in her second pregnancy, having had a previous miscarriage at 7-weeks gestation. They encompass improvements in our understanding of continuous glucose monitoring (CGM) in pregnancy, early data on the first commercially available closed-loop system used (off-license) during pregnancy, and advancements in our understanding of screening for GDM. As CGM in pregnancy continues to gain more widespread use, identifying these patterns using FDA may not only aid in the understanding of the pathophysiology of various glycemic-related complications but also help diabetes clinicians and women with diabetes identify and target patterns to reduce adverse outcomes. The manuscripts chosen for this year's article on technology and pregnancy demonstrated advances in our understanding of type 1, type 2, and gestational diabetes (GDM) in pregnant women. [Extracted from the article]

Background: Women with hypothyroidism before pregnancy often require an increase in their levothyroxine dosage to maintain a euthyroid state during pregnancy. The objectives of this study were to investigate: (i) the frequency and distribution of thyrotropin (TSH) testing and levothyroxine dosage adjustment by gestational age, (ii) the magnitude of levothyroxine increase by the underlying etiology of hypothyroidism, and (iii) the relationship of overtreatment or undertreatment during pregnancy with adverse pregnancy outcomes among women using thyroid replacement before pregnancy. Methods: A retrospective cohort study of pregnancies in women on thyroid replacement before pregnancy in Alberta, Canada, was performed. Women using thyroid replacement anytime during the two years before pregnancy who delivered between October 2014 and September 2017 were included. Delivery records, physician billing, and laboratory and pharmacy administrative data were linked. Outcomes included characteristics of TSH testing, levothyroxine dosing, and pregnancy outcomes. The frequency and gestational timing of TSH testing and levothyroxine adjustments were calculated. Multiple logistic regression was used to test whether pregnancies with TSH <0.10 mIU/L (overtreatment) or TSH ≥10.00 mIU/L (undertreatment) compared with control pregnancies (TSH 0.10–4.00 mIU/L) were associated with adverse pregnancy and neonatal outcomes. Results: Of the 10,680 deliveries, 8774 (82.2%) underwent TSH testing at least once during pregnancy, at a median gestational age of six weeks. An adjustment of levothyroxine dosage was made for 4321 (43.7%) during pregnancy. TSH in pregnancy below 0.10 mIU/L increased the odds of preterm delivery when compared with control pregnancies (adjusted odds ratio, 2.14 [95% confidence interval 1.51–2.78]). TSH ≥10.00 mIU/L during pregnancy was not associated with any adverse pregnancy or neonatal outcomes in the multivariable analysis. Conclusions: Although most women on thyroid replacement before conception had TSH measured at some point during pregnancy, it is concerning that 17.8% did not. Levothyroxine overtreatment in pregnancy was associated with preterm delivery. These findings suggest that clinicians should be careful to avoid overtreatment with levothyroxine in pregnancy. [ABSTRACT FROM AUTHOR]

In recent years, continuous glucose monitoring (CGM) has become increasingly available with the introduction of devices that are specifically approved for use during pregnancy. Evidence in the form of randomized-controlled trials and cohort studies continues to build support for the use of CGM during pregnancy to improve measures of maternal glycemia as well as obstetric and neonatal outcomes. Based on data from the CGM in pregnant women with type 1 diabetes (CONCEPTT) trial alongside a Swedish cohort study of real-world outcomes of pregnant women with type 1 diabetes, the UK National Institute for Health and Clinical Excellence (NICE) guidelines now recommend that real-time CGM be offered to all pregnant women with type 1 diabetes. Based on these guidelines, all pregnant individuals in the United Kingdom with type 1 diabetes will receive government-funded real-time CGM for a 12-month duration. These guidelines are a game-changer and will continue to facilitate more widespread access to CGM use in the United Kingdom and beyond. This review describes the role of CGM in the management of diabetes in pregnancy, discusses contemporary maternal glucose levels and their relationship with outcomes in diabetes pregnancies, and examines the high-quality, randomized-controlled trial and the real-world clinical data evaluating the impact of CGM use. [ABSTRACT FROM AUTHOR]

The manuscripts chosen for this year's technology and pregnancy article provide new insights into fetal exposure to maternal glucose during pregnancies complicated by gestational diabetes, and type 1 diabetes. Data relating continuous glucose monitoring (CGM) in type 1 diabetes pregnancy to neonatal outcomes are scarce. Healthcare providers and women with diabetes can focus on increasing CGM time in range during the latter half of pregnancy to reduce the risk of neonatal hypoglycemia. Women with gestational diabetes were more likely to develop type 2 diabetes or prediabetes than women without gestational diabetes (adjusted OR 3.44 [95% CI 2.84, 4.14]). [Extracted from the article]

Background: Population-, assay-, and trimester-specific reference intervals for thyroid function tests are necessary to assess thyroid status accurately and manage thyroid disease throughout pregnancy. This study's objective was to verify if the manufacturer's recommended trimester-specific reference intervals for thyroid tests and the American Thyroid Association's recommended total thyroxine (TT4) pregnancy reference intervals were verifiable and appropriate for use in the authors' multicultural population. Methods: Blood samples were obtained from the following sources: stored frozen surplus blood from women undergoing routine aneuploidy screening (first- and second-trimester samples, n = 274), women participating in an observational cohort study (second- and third-trimester samples, n = 135), and blood collected from women presenting for assessment to the labor and delivery ward (third-trimester samples, n = 35). Exclusions included thyroid medication or disease and positive thyroid peroxidase antibodies (anti-TPO). Samples were analyzed for thyrotropin (TSH), free T4 (fT4), free triiodothyronine (fT3), TT4, and anti-TPO using the Roche Cobas 8000 Modular e602 electrochemiluminescence immunoassay. Results: Nine percent of the aneuploidy screening samples were excluded prior to thyroid testing due to maternal use of thyroid medication. Six percent of analyzed samples were excluded: 5.9% with positive anti-TPO and one with a TSH >10 mIU/L. The manufacturer's recommended trimester-specific reference intervals for TSH were not verified by described standardized methods. Therefore, 95th percentile reference intervals were determined using a minimum number of samples. Reference intervals for TSH and fT4 were as follows: 9–12 weeks, 0.18–2.99 mIU/L and 11–19.2 pmol/L; second trimester, 0.11–3.98 mIU/L and 10.5–18.2 pmol/L; and third trimester, 0.48–4.71 mIU/L and 9.0–16.1 pmol/L, respectively. The TT4 reference interval after 19 weeks' gestation was 77–186 nmol/L. Conclusions: This study provides a simple approach to verify or establish trimester-specific thyroid function reference intervals in local populations. The TT4 reference interval was lower than the interval proposed by the American Thyroid Association, suggesting the need for further study of TT4 in pregnancy and reliance on locally established fT4 reference intervals after 19 weeks, especially when there are no equivalent reference intervals for TT4. [ABSTRACT FROM AUTHOR]

The article offers information on some key advances in the field of diabetes technology that is increasingly used in the clinical management of diabetes before and during pregnancy. It mentions the real-world data are becoming increasingly important to health-care providers and regulators; and also mentions metabolomic data from the Great Britain describe the metabolite disturbances in obese women 10 weeks prior to gestational diabetes mellitus (GDM) diagnosis.

Tight glucose control during labor and delivery is recommended for pregnant women with type 1 diabetes. This can be challenging to achieve using the current treatment modalities. The automated nature of closed loop and its ability to adapt to real-time glucose levels make it well suited for use during labor, delivery, and the immediate postpartum period. We report observational data of participants from two randomized crossover trials who chose to continue using closed loop during labor, delivery, and postpartum. Labor was defined as the 24 h before delivery and postpartum as the 48 h after delivery. The glucose target range during pregnancy was 3.5-7.8 mmol/L (63-140 mg/dL) and 3.9-10 mmol/L (70-180 mg/dL) after delivery. Twenty-seven (84.4%) of the potential 32 trial participants used closed loop through labor, delivery, and postpartum. Use of closed loop was associated with 82.0% (interquartile range [IQR] 49.3, 93.0) time-in-target range during labor and delivery and a mean glucose of 6.9 ± 1.4 mmol/L (124 ± 25 mg/dL). Closed loop performed well throughout vaginal, elective, and emergency cesarean section deliveries. Postpartum, women spent 83.3% (IQR 75.2, 94.6) time-in-target range (3.9-10.0 mmol/L [70-180 mg/dL]), with a mean glucose of 7.2 ± 1.4 mmol/L (130 ± 25 mg/dL). There was no difference in maternal glucose concentration between mothers of infants with and without neonatal hypoglycemia (6.9 ± 1.6 mmol/L and 6.8 ± 1.1 mmol/L [124 ± 29 mg/dL and 122 ± 20 mg/dL] respectively; P = 0.84). Automated closed-loop insulin delivery is feasible during hospital admissions for labor, delivery, and postpartum. Larger scale studies are needed to evaluate its efficacy compared with current clinical approaches as well as understand how women and healthcare providers will adopt this technology. [ABSTRACT FROM AUTHOR]