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Pregnancy in the setting of type 1 diabetes is associated with an increased risk of adverse outcomes for both mother and fetus. Adequate glycaemic control has been shown to result in improved outcomes, but the strict glycaemic targets required in pregnancy are often difficult to achieve. The development of novel technologies for insulin delivery aim to assist in achieving excellent glycaemic control, while attempting to minimize the significant risk of hypoglycaemia that exists in pregnancy. This review will discuss the use of insulin pump therapy, continuous glucose monitoring and closed loop insulin delivery in the setting of pregestational diabetes, highlighting some of the potential advantages of these technologies. Novel insulin delivery devices have been shown to be safe in the setting of pregnancy, but proper randomized controlled trials are still needed to determine if they are superior to traditional insulin delivery mechanisms. [ABSTRACT FROM AUTHOR]

Objective. To determine whether breastfeeding reduced the risk of childhood obesity in the infants of a multi-ethnic cohort of women with pregestational diabetes. Methods. In this retrospective cohort study, women with pregestational diabetes were mailed a questionnaire about breastfeeding and current height and weight of mothers and infants. Predictors of obesity (weight for age >85 percentile) were assessed among offspring of index pregnancies, using univariate and multivariable logistic regression. Results. Of 125 women, 81 (65%%) had type 1 diabetes and 44 (35%%) had type 2 diabetes. The mean age of offspring was 4.5 years. On univariate analysis, significant predictors of obesity in offspring were type 2 diabetes (odds ratio, OR 2.4, 95%% confidence interval, CI 0.99--5.72); maternal body mass index (BMI) > 25 (OR 4.4, 95%% CI 1.4--19.4); and any breastfeeding (OR 0.22, 95%% CI 0.07--0.72). After multivariable adjustment, breastfeeding (OR 0.20, 95%% CI 0.06--0.69) and having an overweight/obese mother (OR 3.49, 95%% CI 1.03--16.2) remained independently associated with childhood obesity. Conclusion. Breastfeeding significantly decreased the likelihood of obesity in offspring of mothers with pregestational diabetes, independent of maternal BMI and diabetes type. Women with diabetes should be encouraged to breastfeed, given the increased risk of obesity in their children. [ABSTRACT FROM AUTHOR]

Background: Rising concern over the poor level of blood-pressure (BP) control among hypertensive patients has prompted searches for novel ways of managing hypertension. The objectives of this study were to develop and pilot-test a home BP tele-management system that actively engages patients in the process of care. Methods: Phase 1 involved a series of focus-group meetings with patients and primary care providers to guide the system’s development. In Phase 2, 33 diabetic patients with uncontrolled ambulatory hypertension were enrolled in a 4-month pilot study, using a before-and-after design to assess its effectiveness in lowering BP, its acceptability to users, and the reliability of home BP measurements. Results: The system, developed using commodity hardware, comprised a Bluetooth-enabled home BP monitor, a mobile phone to receive and transmit data, a central server for data processing, a fax-back system to send physicians’ reports, and a BP alerting system. In the pilot study, 24-h ambulatory BP fell by 11/5 (±13/7 SD) mm Hg (both P < .001), and BP control improved significantly. Substantially more home readings were received by the server than expected, based on the preset monitoring schedule. Of 42 BP alerts sent to patients, almost half (n = 20) were due to low BP. Physicians received no critical BP alerts. Patients perceived the system as acceptable and effective. Conclusions: The encouraging results of this study provide a strong rationale for a long-term, randomized, clinical trial to determine whether this home BP tele-management system improves BP control in the community among patients with uncontrolled hypertension. [Copyright &y& Elsevier]

Aims: The risk of microvascular disease has been thought to commence with the onset of overt diabetes. Women with gestational diabetes have only had a short-term exposure to frank hyperglycemia, but, due to underlying β-cell dysfunction, they may also have had long-term exposure to mild degrees of hyperglycemia. The aim of the study was to determine whether women with gestational diabetes are at increased risk for microalbuminuria and retinopathy compared to women with normal glucose tolerance in pregnancy.Methods: We recruited women aged ≥ 25 years with singleton pregnancies at 32 to 40 weeks' gestational age, with and without gestational diabetes. Women with hypertension, preeclampsia, or pre-gestational diabetes were excluded.Results: Of 372 women included in the study, 195 had gestational diabetes. The prevalence of microalbuminuria was 15% among those with gestational diabetes versus 6% in those with normal glucose tolerance (adjusted odds ratio 2.4, 95% confidence interval 1.1 to 5.2, p = 0.006). Diastolic blood pressure and HbA1c were associated with microalbuminuria. The prevalence of retinopathy did not differ between groups (10% versus 11%).Conclusions: Women with gestational diabetes have an increased risk of microalbuminuria in the third trimester, despite having been exposed to only a brief period of overt hyperglycemia. [ABSTRACT FROM AUTHOR]

Aims Methods Results Conclusions Women with gestational diabetes mellitus (GDM) have a high risk of developing type 2 diabetes (T2D). Readiness for behaviour change to mitigate this risk may be low after pregnancy and may further decrease over time without appropriate interventions. This study aimed to evaluate readiness for behaviour change in the first and second postpartum years in women with recent GDM to determine the best timing for lifestyle interventions to prevent T2D.This study included a subset of women with GDM between 2009 and 2013 in Ontario, Canada from a larger prospective cohort study who completed a survey in the first and second postpartum years (N = 329). The primary outcome was stage of readiness for behaviour change for diet and physical activity, compared between the first and second postpartum years.The mean age was 34.3 ± 4.4 standard deviation (SD) years and mean pre‐pregnancy body‐mass index (BMI) was 26.7 ± 6.9 kg/m2. In the first postpartum year, 86% of women reported a pre‐action stage of change, which was 87% by the second postpartum year (p = 0.646). Non‐Caucasian ethnicity was associated with lower odds of being in the action stage of readiness for behaviour change overall and for physical activity in both time periods.Most postpartum women with recent GDM are in a pre‐action stage of change after delivery, which does not increase by the second postpartum year. Behavioural interventions should continue to be prioritized in postpartum women with GDM to optimize this slim window of opportunity for T2D prevention. [ABSTRACT FROM AUTHOR]

The article discusses the consensus-based recommendations published by International Association of the Diabetes and Pregnancy Study Groups (IADPSG) panel on the diagnosis and classification of hyperglycemia in pregnancy. Topics discussed include the adoption by World Health Organization (WHO) of the IADPSG criteria and its promotion of the term "diabetes in pregnancy" for this group. It suggests that the threshold of >5.1mmol/L to identify gestational diabetes mellitus (GDM) is not justified.

Purpose Of Review: To review current glycaemic targets and the potential use of newer insulin formulations in pregnancy.Recent Findings: The impact of stricter glycaemic control on perinatal outcomes remains controversial, showing conflicting results. Current ongoing randomised trials investigating the role of tighter glucose targets in pregnancy should help clarify the benefit of tighter glucose control. Optimal timing for self-monitoring blood glucose (SMBG) remains debatable. Data suggest that post-prandial SMBG, particularly at 1 h, offers the best prediction of adverse perinatal outcome. To achieve these targets, insulin is the standard therapy. Novel insulin formulations offer benefits outside of pregnancy. Recent data on the use of new insulins in pregnancy (e.g. insulin degludec and glargine (U 300)) is limited to case reports. Glycaemic targets have remained unchanged in the last decade. Studies using stricter glycaemic targets may improve perinatal outcomes. Newer insulin formulations may offer increased flexibility and glycaemic control. Clinicians caring for women with diabetes striving to minimise adverse perinatal outcomes will find this review of interest. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to examine the influence of immigration status and region of origin on the risk of type 2 diabetes in women with prior gestational diabetes (GDM). Methods: This retrospective population‐based cohort study included women with gestational diabetes (GDM) aged 16 to 50 years in Ontario, Canada, who gave birth between 2006 and 2014. We compared the incidence of type 2 diabetes after delivery between long‐term residents and immigrants—overall, by time since immigration and by region of—using Cox regression adjusted for age, year, neighbourhood income, rurality, infant birth weight and presence of hypertensive disorders of pregnancy (HDP). Results: Among 38,515 women with prior GDM (42% immigrants), immigrants had a significantly higher risk of type 2 diabetes compared with long‐term residents (adjusted hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.13–1.26), with no meaningful difference based on time since immigration. The highest adjusted relative risks of type 2 diabetes compared with long‐term residents were found for immigrants from Sub‐Saharan Africa (HR 1.63, 95% CI 1.40–1.90), Latin America/Caribbean (HR 1.44, 95% CI 1.28–1.62) and South Asia (HR 1.34, 95% CI 1.25–1.44). Conclusions: Immigration is associated with a significantly higher risk of type 2 diabetes after GDM, particularly for women from certain low‐ and middle‐income countries. Diabetes prevention strategies will need to consider the unique needs of immigrants from these regions. [ABSTRACT FROM AUTHOR]

Background: Most commercially available automated insulin delivery (AID) systems are not approved for pregnancy use. Information regarding use of the Tandem t:slim X2 insulin pump with Control‐IQ™ technology in pregnancy is lacking. Aims: This case series aimed to explore glycaemic and qualitative experiences of four early adopters of Control‐IQ technology in pregnancy. Methods: Participants used Control‐IQ technology in pregnancy and postpartum and consented to analysis of glycaemic data and semi‐structured interviews. Results: Case 1 began Control‐IQ technology at 10 weeks gestation. Her pregnancy glucose time‐in‐range (3.5–7.8 mmol/L [63–140 mg/dL]) increased from 58.7% to 73.3% by third trimester. Cases 2–4 began using Control‐IQ technology 0–2 months preconception. Pregnancy time‐in‐range glucose increased from 73.4% to 78.7%, 78% to 83.6%, and 46.5% to 71.9% between first and third trimesters, respectively. A mid‐pregnancy decline in time‐in‐range glucose was observed in two of the four participants related to suboptimal pump setting adjustments and delays in sensor and infusion set replacement. No diabetic ketoacidosis or severe hypoglycaemia occurred. All participants reported reduced diabetes management burden and improved sleep with Control‐IQ technology use. Conclusions: Early adopters of Control‐IQ technology safely used this system off‐label in pregnancy and reported reduced diabetes management burden and improved sleep. The largest glycaemic improvements were observed among those with the lowest pregnancy time‐in‐range glucose at the beginning of pregnancy. Participants with low pregnancy glucose time‐in‐range increased their time‐in‐range with Control‐IQ technology use and participants with high pregnancy glucose time‐in‐range maintained and increased their time‐in‐range with less diabetes management burden. [ABSTRACT FROM AUTHOR]

Background: No standardised questionnaires have been specifically developed to assess the considerable demands of managing type 1 diabetes (T1D) during pregnancy. Aims: This study aimed to explore what domains of measurement are important to quality of life during pregnancy with TID and to assess if standardised questionnaires, used by previous researchers, adequately capture patients' reported experience of TID in pregnancy. Methods: A qualitative inquiry was conducted using semi‐structured focus groups with Canadian women who have experienced T1D in pregnancy. Participants were asked open‐ended questions about experiences managing T1D during pregnancy and whether options on standardised tools captured their pregnancy experiences. Audio from focus groups was transcribed verbatim. Two researchers independently analysed the transcripts using inductive thematic analysis. Salient ideas, experiences and key words were coded iteratively and grouped into broader themes and subsequently reviewed by five participants. Results: The sample included nine participants. Emergent themes included changes in day‐to‐day routines to manage T1D in pregnancy, fear of hyperglycaemia during pregnancy and of hypoglycaemia postpartum. Participants felt that existing options on standardised questionnaires did not adequately quantify diabetes interference in work, family time, planned activities and sleep, and did not address hyperglycaemia fear. Conclusions: Existing standardised questionnaires do not adequately capture patient‐reported outcomes of greatest importance for those living with T1D in pregnancy. Future research assessing the impact of therapies on quality‐of‐life measures in TID pregnancies should quantify their influence on day‐to‐day activities, adjust measures of sleep quality and capture fear of hyperglycaemia in pregnancy and hypoglycaemia postpartum. [ABSTRACT FROM AUTHOR]

Aims: As an indicator of maternal cardiometabolic health, newborn birthweight may be an important predictor of maternal type 2 diabetes mellitus (diabetes). We evaluated the relation between offspring birthweight and onset of maternal diabetes after pregnancy. Methods: This retrospective cohort study used linked population‐based health databases from Ontario, Canada. We included women aged 16–50 years without pre‐pregnancy diabetes, and who had a live birth between 2006 and 2014. We used Cox proportional hazard regression to evaluate the association between age‐ and sex‐standardized offspring birthweight percentile categories and incident maternal diabetes, while adjusting for maternal age, parity, year, ethnicity, gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP). Results were further stratified by the presence of GDM in the index pregnancy. Results: Of 893,777 eligible participants, 14,329 (1.6%) women were diagnosed with diabetes over a median (IQR) of 4.4 (1.5–7.4) years of follow‐up. There was a continuous positive relation between newborn birthweight above the 75th percentile and maternal diabetes. Relative to a birthweight between the 50th and 74.9th percentiles, women whose newborn had a birthweight between the 97th and 100th percentiles had an adjusted hazards ratio (aHR) of diabetes of 2.30 (95% CI 2.16–2.46), including an aHR of 2.01 (95% CI 1.83–2.21) among those with GDM, and 2.59 (2.36–2.84) in those without GDM. Conclusions: A higher offspring birthweight signals an increased risk of maternal diabetes, offering another potentially useful way to identify women especially predisposed to diabetes. [ABSTRACT FROM AUTHOR]

Objective Post-partum thyroiditis ( PPT) is a common phenomenon in the general population. To date there have been few studies examining the incidence of PPT in women with hypothyroidism antedating pregnancy. This study aimed to assess the incidence and potential predictors of PPT in women with treated hypothyroidism antedating pregnancy. Design Retrospective cohort study. Patients and Methods We compiled a cohort of 97 women with previous hypothyroidism antedating pregnancy seen in the Endocrinology in Pregnancy clinic from 1999 to 2011, collecting data on thyroid function, antibodies and levothyroxine doses post-partum. The incidence of PPT and its predictors were analysed. Results A total of 66 (68%) women had fluctuations in thyroid function consistent with PPT. Of these, 22 (33%) had a hyperthyroid phase alone, 22 (33%) had a hypothyroid phase alone and 22 (33%) had both a hyper and hypo phase. The majority of women had their dose of thyroid medication adjusted during the PPT episode. Women who were on a full dose of thyroxine post-partum were significantly less likely to have a hypothyroid phase. In multivariable analysis, the only predictor of PPT was the presence of thyroid antibodies, with 83% of antibody positive women having PPT compared to 44% of antibody negative women ( P = 0·0001). Conclusions In our cohort, 2/3 of women had fluctuations in thyroid function consistent with PPT and most required adjustment of their thyroid dose. Women with hypothyroidism antedating pregnancy are at high risk for PPT and should be closely monitored during the first year post-partum. [ABSTRACT FROM AUTHOR]

Objective: To determine gestational weekly changes in continuous glucose monitoring (CGM) metrics and 24-h glucose profiles and their relationship to infant birth weight in pregnant women with type 1 diabetes.Research Design and Methods: An analysis of >10.5 million CGM glucose measures from 386 pregnant women with type 1 diabetes from two international multicenter studies was performed. CGM glucose metrics and 24-h glucose profiles were calculated for each gestational week, and the relationship to normal (10-90th percentile) and large (>90th percentile) for gestational age (LGA) birth weight infants was determined.Results: Mean CGM glucose concentration fell and percentage of time spent in the pregnancy target range of 3.5-7.8 mmol/L (63-140 mg/dL) increased in the first 10 weeks of pregnancy and plateaued until 28 weeks of gestation, before further improvement in mean glucose and percentage of time in range until delivery. Maternal CGM glucose metrics diverged at 10 weeks of gestation, with significantly lower mean CGM glucose concentration (7.1 mmol/L; 95% CI 7.05-7.15 [127.8 mg/dL; 95% CI 126.9-128.7] vs. 7.5 mmol/L; 95% CI 7.45-7.55 [135 mg/dL; 95% CI 134.1-135.9]) and higher percentage of time in range (55%; 95% CI 54-56 vs. 50%; 95% CI 49-51) in women who had normal versus LGA. The 24-h glucose profiles were significantly higher across the day from 10 weeks of gestation in LGA.Conclusions: Normal birth weight is associated with achieving significantly lower mean CGM glucose concentration across the 24-h day and higher CGM time in range from before the end of the first trimester, emphasizing the need for a shift in clinical management, with increased focus on using weekly CGM glucose targets for optimizing maternal glycemia from early pregnancy. [ABSTRACT FROM AUTHOR]

Aims: Our study assesses perinatal outcomes among women with type 2 diabetes, with gestational weight gain (GWG) within and outside of US Institute of Medicine (IOM) guidelines, by conducting a secondary analysis of the Metformin in Type 2 Diabetes in Pregnancy (MiTy) trial.Methods: 460 participants were classified into three cohorts by total and weekly GWG (excessive, appropriate vs. restricted according to IOM). The primary outcome was birthweight z score, and secondary outcomes included both maternal and fetal outcomes.Results: Women with restricted (total and weekly) GWG had lower birthweight z score, lower fetal birthweight, and lower neonatal body fat mass. Women with restricted weekly GWG had fewer LGA, extreme LGA, and lower neonatal body fat mass infants, but more SGA and preterm births. Women with excessive (total and weekly) GWG had higher maternal total insulin doses in the third trimester. Women with excessive weekly GWG had more preeclampsia and higher SGA.Conclusions: Restricted GWG among women with type 2 diabetes is associated with both benefits and harms. Both must be considered when counseling patients. [ABSTRACT FROM AUTHOR]

Aims: To examine maternal fear of hypoglycaemia, glycaemia and pregnancy outcomes in women with impaired and normal awareness of hypoglycaemia. Methods: A pre‐planned sub‐study of 214 pregnant women with type 1 diabetes who participated in the CONCEPTT trial. Participants completed hypoglycaemia fear surveys (HFS‐II) at baseline. Logistic regression and Poisson regression analyses were used to obtain an adjusted estimate for the rate ratio relating awareness to the number of severe hypoglycaemic episodes, and for several neonatal outcomes in relation to the total HFS‐II score. The role of continuous glucose monitoring (CGM) use was examined. Results: Overall, 30% of participants reported impaired awareness of hypoglycaemia (n = 64). Women with impaired awareness of hypoglycaemia had more episodes of severe hypoglycaemia (mean 0.44 vs. 0.08, p < 0.001) (12–34 weeks gestation) and scored higher on the HFS‐II scale (43.7 vs. 36.0, p 0.008), indicating more fear of hypoglycaemia. They spent more time below range (CGM <3.5 mmol/L) and exhibited more glycaemic variability at 12 weeks gestation. Higher overall HFS‐II scores were associated with a higher risk of maternal severe hypoglycaemia episodes (Rate Ratio 1.78, 95% CI 1.39–2.27). Women with impaired awareness of hypoglycaemia had less maternal weight gain but there were no differences in neonatal outcomes between women with impaired awareness of hypoglycaemia and normal hypoglycaemia awareness. Higher HFS‐II scores were associated with more nephropathy (Odds Ratio 1.91, 95% CI 1.06–3.4). CGM use after 12 weeks was not associated with the number of episodes of severe hypoglycaemia (RR 0.75, 95% CI 0.49–1.15; p = 0.18). Conclusions: In pregnant women with type 1 diabetes, impaired awareness of hypoglycaemia is associated with more maternal severe hypoglycaemia episodes and more fear of hypoglycaemia. Having impaired awareness of hypoglycaemia and/or fear of hypoglycaemia should alert clinicians to this increased risk. Reassuringly, there was no increase in adverse neonatal outcomes. [ABSTRACT FROM AUTHOR]

Aims: Glucose tolerance normalizes postpartum in most women with gestational diabetes (GDM), which may provide false reassurance and decrease weight-reducing behaviours. We evaluated whether awareness of normal postpartum glucose tolerance was associated with higher weight retention than being unaware of glucose tolerance.Methods: This cohort study of women with GDM collected survey data during pregnancy and in the first and second postpartum year. We compared women who reported normal glucose tolerance ('aware, normal') in the first year to those reporting no testing or unsure of results ('unaware'). The primary outcome was self-reported weight in the second year compared between groups using multivariable linear regression.Results: Among 319 women, 110 (34.5%) were 'aware, normal'; 183 (57.4%) were 'unaware'; and 26 (8.2%) were 'aware, abnormal'. After adjusting for baseline weight and covariates, women with normal results had a mean 3.66 kg higher weight (CI 1.08-6.24 kg, p = 0.0056) by the second year than those unaware of results.Conclusions: Women with GDM with normal postpartum glucose tolerance had significantly higher weight by the second year than those unaware of their results. Normal glucose tolerance after pregnancy may be misinterpreted as resolution of diabetes risk and decrease risk-reducing behaviours. [ABSTRACT FROM AUTHOR]

Background: Cold-induced thermogenesis is known to improve insulin sensitivity, which may become increasingly relevant in the face of global warming. The aim of this study was to examine the relation between outdoor air temperature and the risk of gestational diabetes mellitus.Methods: We identified all births in the Greater Toronto Area from 2002 to 2014 using administrative health databases. Generalized estimating equations were used to examine the relation between the mean 30-day outdoor air temperature before the time of gestational diabetes mellitus screening and the likelihood of diagnosis of gestational diabetes mellitus based on a validated algorithm using hospital records and physician service claims.Results: Over the 12-year period, there were 555 911 births among 396 828 women. Prevalence of gestational diabetes mellitus was 4.6% among women exposed to extremely cold mean outdoor air temperatures (≤ -10°C) in the 30-day period before screening and increased to 7.7% among those exposed to hot mean 30-day temperatures (≥ 24°C). Each 10°C increase in mean 30-day temperature was associated with a 1.06 (95% confidence interval [CI] 1.04-1.07) times higher odds of gestational diabetes mellitus, after adjusting for maternal age, parity, neighbourhood income quintile, world region and year. A similar effect was seen for each 10°C rise in outdoor air temperature difference between 2 consecutive pregnancies for the same woman (adjusted odds ratio 1.06, 95% CI 1.03-1.08).Interpretation: In our setting, there was a direct relation between outdoor air temperature and the likelihood of gestational diabetes mellitus. Future climate patterns may substantially affect global variations in the prevalence of diabetes, which also has important implications for the prevention and treatment of gestational diabetes mellitus. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Ivanisevic and Djelmis publishing descriptions of the cohort of pregnant women with type 1 diabetes (T1D) (2). Topics include suboptimal glycemia and higher cord C-peptide, consistent with fetal hyperinsulinemia, and striking rates of neonatal morbidity; and fetal C-peptide crossing the placenta into maternal circulation in late pregnancy.