A pregnant woman is looking at her smartphone to see the values of her...

Article • Automated glucose monitoring

Pregnancy and diabetes: reducing complications with technology

Women with type 1 or type 2 diabetes often have difficulty getting pregnant, due to complications from the disease, being obese or seriously underweight, or having conditions like polycystic ovary syndrome. Once pregnant, they face challenges of having a safe pregnancy and delivering a healthy baby. Recent advances in diabetes technology, including continuous glucose monitoring (CGM) and most recently hybrid closed-loop (HCL) insulin delivery systems, can help women meet their pregnancy glucose targets and achieve significantly better health outcomes for themselves and their infant.

Report: Cynthia E. Keen

Prof. Helen R. Murphy, MD, a practicing clinician at Norfolk & Norwich University Hospital NHS Trust, UK, and a Professor of Medicine in Diabetes and Antenatal Care at the University of East Anglia, co-led both major clinical trials evaluating the impact of CGM and HCL. She now advocates for the rapid adoption of HCL over CGM, explaining the advantages of each when delivering the American Diabetes Association’s Norbert Freinkel Award Lecture, an annual honorary recognition of outstanding contributions to the understanding and treatment of diabetes and pregnancy.

For one, HCL is easier to use, the expert pointed out. The technology, also known as an “artificial pancreas”, links an insulin pump and CGMs to enable delivery of insulin automatically using a calculation based on continuous glucose measurements. In December 2023, NICE published recommendations that the technology should be used by diabetic patients who have a high HbA1c, as well as for women who are pregnant or planning to be.¹

CONCEPTT trial insights

The international, randomized CONCEPTT (Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Clinical Trial) led to changes in clinical guidelines for pregnant pre-pregnancy diabetic women. CGM systems track blood sugar levels in real time 24 hours a day and enable a diabetic person to take immediate action to restore blood sugar to appropriate levels. The pregnant cohort who used a real-time CGM system maintained better and more consistent glycaemic control than those who were self-monitoring their capillary blood glucose (SMBG) levels. Use of CGM is now recommended as standard of care, because it is significantly better than SMBG, which only provides a single glucose value at a given time.²

The CONCEPTT trial data revealed that CGM alone will not be adequate for most women to achieve and maintain optimal glucose levels throughout T1D pregnancy
Helen Murphy

Hyperglycaemia is associated with increased risk of preeclampsia, developing an excessive amount of amniotic fluid (polyhydramnios) in the womb that can cause pregnancy and delivery complications, requiring a caesarean section, or having a miscarriage or stillbirth. Infants may have increased rates of congenital abnormalities, premature delivery, being large for their gestational age, and/or require admission to a neonatal intensive care unit (NICU).³ Obesity also causes pregnancy risks, and many pregnant women are also obese.

The CONCEPTT trial demonstrated that, with strict adherence to CGM, 16% fewer oversized infants were born, 13% fewer had low blood sugar levels, and that half as many were admitted to NICUs, with 16% fewer staying for more than 24 hours. The trial’s findings have been deemed by experts similarly applicable to women with type 2 diabetes.

‘But the CONCEPTT trial data revealed that CGM alone will not be adequate for most women to achieve and maintain optimal glucose levels throughout T1D pregnancy,’ said Murphy. ‘Secondary analyses from CONCEPTT demonstrated that 10% of participants achieved the recommended time-in-target-range during the first and second trimesters, only rising to 35% by 35 weeks’ gestation.’

Communication with care providers is critical

The Augmented Insulin Delivery Amongst Pregnant women with Type 1 diabetes (AIDAPT) randomised clinical trial investigated if HCL improved outcomes over CGM. It did, on many levels: Almost all patients were using CGM prior to pregnancy. For the trial, half were switched to HCL. These women had significantly improved maternal glucose levels by the end of the first trimester and maintained a high level of glycaemic control compared to the CGM group. They had 3.7 kg average less weight gain. Their babies were delivered 4.5 days earlier, with lower rates of large-for-gestational-age birth weight babies.

Research studies with larger groups are needed to validate these clinical findings. Use of the HCL system was still challenging for many of the AIDAPT participants. All agreed that interactive communication with care providers is of critical importance, because they received better and more timely health care team input. And some were able to stay at their jobs longer before taking maternity leave, a very important factor for low-income women.

Murphy is optimistic that continuing technology advancements will continue to improve the odds of a less troublesome pregnancy and a healthy infant for women with pre-pregnancy diabetes.

Profile:

Dr Helen Murphy is a Professor of Medicine (Diabetes and Antenatal Care) at the University of East Anglia, UK, and a practicing clinician at the Norfolk & Norwich University Hospital NHS Trust, and at Cambridge University NHS Foundation Trust. She runs a diabetes pregnancy research programme which aims to support women with diabetes to achieve the pregnancy glucose targets required for optimal mother and baby health outcomes. Dr Murphy serves as clinical lead for the National Pregnancy in Diabetes (NPID) audit, which is the largest population-based study in diabetes pregnancy.

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04.11.2024