Optimizing Diabetes-in-Pregnancy Outcomes Requires a Care Continuum

Audrey M. Huang; Menachem Miodovnik; E. Albert Reece

doi:10.1055/a-2505-5330

American Journal of Perinatology, Table of Contents

Am J Perinatol
DOI: 10.1055/a-2505-5330

Review Article

Optimizing Diabetes-in-Pregnancy Outcomes Requires a Care Continuum

Audrey M. Huang

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Center for Advanced Research Training and Innovation, University of Maryland School of Medicine, Baltimore, Maryland

,

Menachem Miodovnik

²Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia

,

E. Albert Reece

³Center for Advanced Research Training and Innovation, Center for Birth Defects Research, University of Maryland School of Medicine, Baltimore, Maryland

› Author Affiliations

Abstract

This study aimed to assess the strengths, limitations, opportunities, and threats presented by diabetes-in-pregnancy. We review the improvements in maternal and fetal mortality since the advent of insulin therapy, evaluate current health challenges, and identify opportunities for preventing increased mortality due to diabetes-in-pregnancy. Prior to 1922, women with type 1 diabetes mellitus (T1DM) of childbearing age were discouraged from becoming pregnant as the maternal and fetal/neonatal mortality rates were extremely high. Starvation-level dietary restriction was the only “treatment,” with limited success in managing the disease. The discovery of insulin coupled with careful clinical management presented the possibility of successful pregnancies for women with T1dm. Over the course of the next half-century, maternal survival increased from 54 to 97%. However, the gains made in reducing adverse outcomes of diabetes in pregnancy are eroding due to modern challenges. The global obesity epidemic has led to an increase in type 2 and gestational diabetes mellitus (DM). T1DM also is on the rise. Together, the rise in the prevalence of pregestational diabetes has increased the risks for adverse outcomes. Here we review the ongoing challenges as well as opportunities for research to improve outcomes. We suggest that overweight, obesity, and diabetes management must be coupled with preconception counseling and education and must include, in addition to, Ob/Gyns, primary care, nutrition, weight management, and other experts to ensure that those at risk of pregnancy complications due to diabetes have the best possible outcomes.

Key Points

Diabetes in pregnancy is affecting more people.
The obesity epidemic is fueling an increase in pregestational diabetes.
Research is needed to reduce inequities in diabetes in pregnancy outcomes.
Blood glucose control should start prior to pregnancy.

Keywords

diabetes mellitus - pregestational diabetes - pregnancy complications - maternal obesity - pregnancy in diabetics - preconception counseling - glycemic control

Full Text

References

References
1 Harvard Health Publishing. People with type 1 diabetes are living longer. Harvard Health Blog. January 8, 2015. Accessed October 1, 2024 at: https://www.health.harvard.edu/blog/people-type-1-diabetes-living-longer-201501087611
2 Vargas R, Repke JT, Ural SH. Type 1 diabetes mellitus and pregnancy. Rev Obstet Gynecol 2010; 3 (03) 92-100
3 Dunn PM. Dr Priscilla White (1900-1989) of Boston and pregnancy diabetes. Arch Dis Child Fetal Neonatal Ed 2004; 89 (03) F276-F278
4 Mazur A. Why were “starvation diets” promoted for diabetes in the pre-insulin period?. Nutr J 2011; 10: 23
5 Beth Israel Lahey Health | Joslin Diabetes Center. Dr. Pricilla White's Legacy Changed Diabetes Care. Accessed October 1, 2024 at: https://joslin.org/news-stories/all-news-stories/stories/2022/03/dr-pricilla-whites-legacy-changed-diabetes-care
6 White P. Pregnancy complicating diabetes. Am J Med 1949; 7 (05) 609-616
7 White P. Classification of obstetric diabetes. Am J Obstet Gynecol 1978; 130 (02) 228-230
8 Wikipedia. Priscilla White (physician). 2024. Accessed October 1, 2024 at: https://en.wikipedia.org/w/index.php?title=Priscilla_White_(physician)&oldid=1238393321
9 March of Dimes. Annual reports and financial information. Accessed October 1, 2024 at: https://www.marchofdimes.org/about-us/annual-reports
10 Gregory EC, Ely DM. Trends and characteristics in gestational diabetes: United States, 2016-2020. Natl Vital Stat Rep 2022; 71 (03) 1-15
11 Gregory ECW, Ely DM. Trends and characteristics in prepregnancy diabetes: United States, 2016-2021. Natl Vital Stat Rep 2023; 72 (06) 1-13
12 Gregory ECW, Valenzuela CP, Martin JA. Fetal mortality in the United States: Final 2020–2021 and 2021-Provisional 2022. 2023. Accessed October 1, 2024 at: https://stacks.cdc.gov/view/cdc/133319
13 CDC. Surveillance - United States Diabetes Surveillance System. Accessed December 2, 2024 at: https://gis.cdc.gov/grasp/diabetes/diabetesatlas-surveillance.html
14 Seneviratne SN, Rajindrajith S. Fetal programming of obesity and type 2 diabetes. World J Diabetes 2022; 13 (07) 482-497
15 Ye W, Luo C, Huang J, Li C, Liu Z, Liu F. Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis. BMJ 2022; 377: e067946
16 Yong HY, Mohd Shariff Z, Mohd Yusof BN. et al. Independent and combined effects of age, body mass index and gestational weight gain on the risk of gestational diabetes mellitus. Sci Rep 2020; 10 (01) 8486
17 Hart BN, Shubrook JH, Mason T. Pregestational diabetes and family planning. Clin Diabetes 2021; 39 (03) 323-328
18 Gale EAM. The rise of childhood type 1 diabetes in the 20th century. Diabetes 2002; 51 (12) 3353-3361
19 Krolewski AS, Warram JH, Rand LI, Kahn CR. Epidemiologic approach to the etiology of type I diabetes mellitus and its complications. N Engl J Med 1987; 317 (22) 1390-1398
20 CDC. Diabetes ǀ National Diabetes Statistics Report. July 23, 2024. Accessed October 1, 2024 at: https://www.cdc.gov/diabetes/php/data-research/index.html
21 Patterson CC, Harjutsalo V, Rosenbauer J. et al. Trends and cyclical variation in the incidence of childhood type 1 diabetes in 26 European centres in the 25 year period 1989-2013: a multicentre prospective registration study. Diabetologia 2019; 62 (03) 408-417
22 Divers J, Mayer-Davis EJ, Lawrence JM. et al. Trends in incidence of type 1 and type 2 diabetes among youths - selected counties and Indian reservations, United States, 2002-2015. MMWR Morb Mortal Wkly Rep 2020; 69 (06) 161-165
23 CDC. Childhood Obesity Facts. Obesity. June 4, 2024. Accessed January 16, 2024 at: https://www.cdc.gov/obesity/childhood-obesity-facts/childhood-obesity-facts.html
24 Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016. JAMA 2018; 319 (16) 1723-1725
25 Chu SY, Callaghan WM, Kim SY. et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care 2007; 30 (08) 2070-2076
26 Ayyash MK, McLaren Jr. R, Shaman M, Al-Kouatly HB. Trends in preeclampsia risk factors in the US from 2010 to 2021. JAMA 2024; 332 (02) 167-169
27 Cameron NA, Petito LC, Shah NS. et al. Association of birth year of pregnant individuals with trends in hypertensive disorders of pregnancy in the United States, 1995-2019. JAMA Netw Open 2022; 5 (08) e2228093
28 World Health Organization. The Global Health Observatory ǀ Indicator Metadata Registry Details. Accessed October 1, 2024 at: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622#:~
29 Hoyert DL. Health E-stat: Maternal mortality rates in the United States, 2022. Accessed October 1, 2024 at: https://stacks.cdc.gov/view/cdc/152992
30 Gunja MZ, Gumas ED, Masitha R, Zephyrin LC. Insights into the U.S. Maternal Mortality Crisis: An International Comparison. The Commonwealth Fund. June 2024
31 CDC. Maternal Mortality Prevention ǀ Pregnancy Mortality Surveillance System. May 20, 2024. Accessed October 1, 2024 at: https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance/index.html
32 Rossen LM, Womack LS, Hoyert DL, Rn A, Uddin SFG. The Impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. 2020. Accessed October 1, 2024 at: https://stacks.cdc.gov/view/cdc/84767
33 Joseph KS, Boutin A, Lisonkova S. et al. Maternal mortality in the United States: recent trends, current status, and future considerations. Obstet Gynecol 2021; 137 (05) 763-771
34 ACOG. Despite New Manuscript, Incontrovertible Evidence Proves the Unacceptably High U.S. Maternal Mortality Rate. 2024. Accessed October 1, 2024 at: https://www.acog.org/news/news-releases/2024/03/despite-new-manuscript-incontrovertible-evidence-proves-unacceptably-high-us-maternal-mortality-rate
35 Dabelea D, Bell RA, D'Agostino Jr. RB. et al; Writing Group for the SEARCH for Diabetes in Youth Study Group. Incidence of diabetes in youth in the United States. JAMA 2007; 297 (24) 2716-2724
36 Wagenknecht LE, Lawrence JM, Isom S. et al; SEARCH for Diabetes in Youth study. Trends in incidence of youth-onset type 1 and type 2 diabetes in the USA, 2002-18: results from the population-based SEARCH for Diabetes in Youth study. Lancet Diabetes Endocrinol 2023; 11 (04) 242-250
37 CDC. QuickStats: Percentage of Mothers with Gestational Diabetes,* by Maternal Age - National Vital Statistics System, United States, 2016 and 2021. MMWR Morb Mortal Wkly Rep 2023; 72 (01) 16
38 CDC. QuickStats: Age-Adjusted* Percentage of Adults Aged ≥20 Years with Diabetes,† by Race and Hispanic Ethnicity—National Health and Nutrition Examination Survey, United States, 1999–2002 and 2009–2012. Accessed October 1, 2024 at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6421a8.htm
39 CDC. Diabetes ǀ Appendix A: Detailed Tables. May 22, 2024. Accessed October 1, 2024 at: https://www.cdc.gov/diabetes/php/data-research/appendix.html
40 Harrington KA, Cameron NA, Culler K, Grobman WA, Khan SS. Rural-urban disparities in adverse maternal outcomes in the United States, 2016-2019. Am J Public Health 2023; 113 (02) 224-227
41 Saving Rural Hospitals. The Crisis in Rural Health Care. Accessed October 1, 2024 at: https://ruralhospitals.chqpr.org/
42 Gamble M. Becker's Hospital CFO Report ǀ 20 states with most rural hospital closures. April 29, 2024. Accessed October 1, 2024 at: https://www.beckershospitalreview.com/finance/20-states-with-most-rural-hospital-closures.html
43 MedPage Today. More Rural Hospitals Are on the Verge of Closing. August 9, 2024. Accessed October 1, 2024 at: https://www.medpagetoday.com/hospitalbasedmedicine/generalhospitalpractice/111463
44 Kozhimannil KB, Interrante JD, Carroll C. et al. Obstetric care access at rural and urban hospitals in the United States. JAMA 2024; x: e2423010
45 March of Dimes. Maternity care deserts report. Accessed December 4, 2024 at: https://www.marchofdimes.org/maternity-care-deserts-report-2022
46 Rossen LM, Hamilton BE, Abma JC. et al. Updated Methodology to Estimate Overall and Unintended Pregnancy Rates in the United States. 2023. Accessed October 1, 2024 at: https://stacks.cdc.gov/view/cdc/124395
47 Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C, Howell EA. Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery. Birth 2016; 43 (01) 20-27
48 The White House. The White House Blueprint for Addressing the Maternal Health Crisis: Two Years of Progress. The White House. July 10, 2024. Accessed October 1, 2024 at: https://www.whitehouse.gov/briefing-room/statements-releases/2024/07/10/the-white-house-blueprint-for-addressing-the-maternal-health-crisis-two-years-of-progress/
49 Khoury JC, Miodovnik M, Mimouni FB, Ehrlich S, Szcznesiak R, Rosenn B. A queen city legacy: 45 years of research in pregnant women with insulin-dependent diabetes mellitus, The Diabetes in Pregnancy Program Project Grant. Am J Perinatol 2024; (e-pub ahead of print).
50 Bearak JM, Popinchalk A, Beavin C. et al. Country-specific estimates of unintended pregnancy and abortion incidence: a global comparative analysis of levels in 2015-2019. BMJ Glob Health 2022; 7 (03) e007151
51 Dude AM, Schueler K, Schumm LP, Murugesan M, Stulberg DB. Preconception care and severe maternal morbidity in the United States. Am J Obstet Gynecol MFM 2022; 4 (02) 100549
52 Willhoite MB, Bennert Jr. HW, Palomaki GE. et al. The impact of preconception counseling on pregnancy outcomes. The experience of the Maine Diabetes in Pregnancy Program. Diabetes Care 1993; 16 (02) 450-455
53 Ferry P, Dunne FP, Meagher C, Lennon R, Egan AM, Newman C. Attendance at pre-pregnancy care clinics for women with type 1 diabetes: a scoping review. Diabet Med 2023; 40 (03) e15014
54 Marshall CJ, Parham L, Hubbard E, Irani RA. Experiences of preconception counseling among pregnant women with preexisting diabetes: opportunities to improve patient-centered care. Int J Environ Res Public Health 2023; 20 (04) 2908
55 American Society for Metabolic and Bariatric Surgery. Metabolic and Bariatric Surgery. July 1, 2021. Accessed October 1, 2024 at: https://asmbs.org/resources/metabolic-and-bariatric-surgery/
56 ACOG. Bariatric Surgery and Pregnancy. Accessed October 1, 2024. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2009/06/bariatric-surgery-and-pregnancy
57 Pg Baharuddin DM, Payus AO, Abdel Malek Fahmy EH. et al. Bariatric surgery and its impact on fertility, pregnancy and its outcome: a narrative review. Ann Med Surg (Lond) 2021; 72: 103038
58 Boller MJ, Xu F, Lee C, Sridhar S, Greenberg MB, Hedderson MM. Perinatal outcomes after bariatric surgery compared with a matched control group. Obstet Gynecol 2023; 141 (03) 583-591
59 Eccles-Smith J, Griffin A, McIntyre HD, Nitert MD, Barrett HL. Pregnancy and offspring outcomes after prepregnancy bariatric surgery. Am J Obstet Gynecol 2024; S0002-9378 (24)00899-8
60 Drucker DJ. Mechanisms of action and therapeutic application of glucagon-like peptide-1. Cell Metab 2018; 27 (04) 740-756
61 Drummond RF, Seif KE, Reece EA. Glucagon-like peptide-1 receptor agonist use in pregnancy: a review. Am J Obstet Gynecol 2024; 232: 17-25
62 Siega-Riz AM, Bodnar LM, Stotland NE, Stang J. The current understanding of gestational weight gain among women with obesity and the need for future research. NAM Perspect 2020; 2020: 10.31478/202001a
63 Battelino T, Danne T, Bergenstal RM. et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care 2019; 42 (08) 1593-1603
64 Sobhani NC, Goemans S, Nguyen A. et al. Continuous glucose monitoring in pregnancies with type 1 diabetes: small increases in time-in-range improve maternal and perinatal outcomes. Am J Obstet Gynecol 2024; 231 (04) 467.e1-467.e8
65 Yang P, Zhao Z, Reece EA. Activation of oxidative stress signaling that is implicated in apoptosis with a mouse model of diabetic embryopathy. Am J Obstet Gynecol 2008; 198 (01) 130.e1-130.e7
66 Li X, Weng H, Xu C, Reece EA, Yang P. Oxidative stress-induced JNK1/2 activation triggers proapoptotic signaling and apoptosis that leads to diabetic embryopathy. Diabetes 2012; 61 (08) 2084-2092