Am J Perinatol
DOI: 10.1055/a-2494-2157
Original Article

Relationship between Intrapartum Continuous Glucose Monitoring Values and Neonatal Hypoglycemia in Individuals with Diabetes

1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
2   Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
,
Sarah A. Nazeer
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Joycelyn Ashby Cornthwaite
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Sean C. Blackwell
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Claudia Pedroza
3   Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
,
Suneet P. Chauhan
4   Delaware Center of Maternal-Fetal Medicine at Christiana Care, Department of Obstetrics, Gynecology, and Reproductive Sciences, Newark, Delaware
,
Antonio Saad
5   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
,
George Saade
5   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
,
Baha M. Sibai
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
› Author Affiliations
Funding Study devices were provided by Dexcom Inc. No additional funding was provided. Dexcom had no role in study design, data collection, analysis, interpretation, or manuscript writing.

Abstract

Objective We aimed to evaluate the relationship between intrapartum continuous glucose monitoring (CGM) and neonatal hypoglycemia (NH) in individuals with diabetes.

Study Design a multicenter prospective study (November 2021–December 2022) of laboring individuals with pregestational or gestational diabetes at ≥34 weeks. Cohorts had a blinded CGM placed from admission through delivery and were monitored with fingerstick (FS) according to usual care. The primary outcome was NH. Secondary neonatal outcomes included neonatal intensive care unit (NICU) length of stay, need for intravenous (IV) glucose therapy, hyperbilirubinemia, respiratory distress, or respiratory distress syndrome. Time in the target range (TIR; range 70–110 mg/dL) and time above the target range (TAR; >110 mg/dL) were expressed as a percentage of all CGM readings, and mean glucose was obtained. Youden index was used to choose the cut point for TAR and prediction of NH.

Results Of 9,479 deliveries during the study period, 202 (2.1%) met the inclusion criteria, and 112 (56%) participants were enrolled (n = 7 did not have available CGM data). Of the study participants, 45 (40%) had pregestational diabetes, and 67 (60%) had gestational diabetes. The mean glucose in labor using a CGM was 102.6 mg/dL (interquartile range [IQR]:89.9, 113.5 mg/dL), and the average percentage of TIR was 62.1% (IQR, 36.9, 85.6). CGM and FS were poor predictors of NH, with no differences in area under the curve (AUC) of mean glucose as a predictor (0.64, 95% CI: 0.48–0.23 vs. 0.53, 95% CI: 0.4–0.6, respectively). The best cut-off for the prediction of NH was a TAR of 61%, with 23% (n = 24) being above the threshold. The rate of NH for TAR >61% versus ≤61% was 45.8 versus 25.9% (p = 0.06). Neonates born to individuals with TAR >61% were more likely to require continuous positive airway pressure after delivery and had a higher cord c-peptide level.

Conclusion In this prospective study of laboring individuals with diabetes, intrapartum CGM TAR was associated with a higher rate of NH.

Key Points

  • CGM use in labor is feasible with a complete glucose profile in the various stages of labor.

  • Best cut-off for predicting NH was a time above range (≥110 mg/dl) of >61%.

  • CGM and FS were poor predictors of NH.

Note

This study was presented as a poster presentation at the Annual Scientific Meeting of the Society for Maternal-Fetal Medicine in Maryland on February 10, 2024.


Supplementary Material



Publication History

Received: 10 November 2024

Accepted: 01 December 2024

Accepted Manuscript online:
02 December 2024

Article published online:
28 December 2024

© 2024. Thieme. All rights reserved.

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333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Gregory E, Ely DM. Data from: Trends and characteristics in gestational diabetes: United States, 2016–2020. Natl Vital Stat Rep 2022; 71: 1-15
  • 2 Shah NS, Wang MC, Freaney PM. et al. Trends in gestational diabetes at first live birth by race and ethnicity in the US, 2011-2019. JAMA 2021; 326 (07) 660-669
  • 3 Powe CE, Carter EB. Racial and ethnic differences in gestational diabetes: time to get serious. JAMA 2021; 326 (07) 616-617
  • 4 Getahun D, Nath C, Ananth CV, Chavez MR, Smulian JC. Gestational diabetes in the United States: temporal trends 1989 through 2004. Am J Obstet Gynecol 2008; 198 (05) 525.e1-525.e5
  • 5 Edwards T, Harding JE. Clinical aspects of neonatal hypoglycemia: a mini review. Front Pediatr 2021; 8: 562251
  • 6 McKinlay CJD, Alsweiler JM, Anstice NS. et al; Children With Hypoglycemia and Their Later Development (CHYLD) Study Team. Association of neonatal glycemia with neurodevelopmental outcomes at 4.5 years. JAMA Pediatr 2017; 171 (10) 972-983
  • 7 Kaiser JR, Bai S, Gibson N. et al. Association between transient newborn hypoglycemia and fourth-grade achievement test proficiency: a population-based study. JAMA Pediatr 2015; 169 (10) 913-921
  • 8 Edwards T, Alsweiler JM, Gamble GD. et al. Neurocognitive outcomes at age 2 years after neonatal hypoglycemia in a cohort of participants from the hPOD randomized trial. JAMA Netw Open 2022; 5 (10) e2235989
  • 9 Diabetes in pregnancy: management from preconception to the postnatal period. National Institute for Health and Care Excellence: Clinical Guidelines. 2020
  • 10 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 201: Pregestational diabetes mellitus. Obstet Gynecol 2018; 132 (06) e228-e248
  • 11 Cheng AY. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Introduction. Can J Diabetes 2013; 37 (Suppl. 01) S1-S3
  • 12 Alberti KG, Thomas DJ. The management of diabetes during surgery. Br J Anaesth 1979; 51 (07) 693-710
  • 13 West TE, Lowy C. Control of blood glucose during labour in diabetic women with combined glucose and low-dose insulin infusion. BMJ 1977; 1 (6071) 1252-1254
  • 14 Nattrass M, Alberti KG, Dennis KJ, Gillibrand PN, Letchworth AT, Buckle AL. A glucose-controlled insulin infusion system for diabetic women during labour. BMJ 1978; 2 (6137) 599-601
  • 15 Caplan RH, Pagliara AS, Beguin EA. et al. Constant intravenous insulin infusion during labor and delivery in diabetes mellitus. Diabetes Care 1982; 5 (01) 6-10
  • 16 Miodovnik M, Mimouni F, Tsang RC. et al. Management of the insulin-dependent diabetic during labor and delivery. Influences on neonatal outcome. Am J Perinatol 1987; 4 (02) 106-114
  • 17 Lean ME, Pearson DW, Sutherland HW. Insulin management during labour and delivery in mothers with diabetes. Diabet Med 1990; 7 (02) 162-164
  • 18 Yamamoto JM, Benham J, Mohammad K, Donovan LE, Wood S. Intrapartum glycaemic control and neonatal hypoglycaemia in pregnancies complicated by diabetes: a systematic review. Diabet Med 2018; 35 (02) 173-183
  • 19 Joshi T, Oldmeadow C, Attia J, Wynne K. The duration of intrapartum maternal hyperglycaemia predicts neonatal hypoglycaemia in women with pre-existing diabetes. Diabet Med 2017; 34 (05) 725-731
  • 20 Yamamoto JM, Donovan LE, Mohammad K, Wood SL. Severe neonatal hypoglycaemia and intrapartum glycaemic control in pregnancies complicated by type 1, type 2 and gestational diabetes. Diabet Med 2020; 37 (01) 138-146
  • 21 Alrais M, Ward C, Cornthwaite JAA. et al. Type 2 diabetes and neonatal hypoglycemia: role of route of delivery and insulin infusion. J Matern Fetal Neonatal Med 2022; 35 (25) 7445-7451
  • 22 Yu Q, Aris IM, Tan KH, Li LJ. Application and utility of continuous glucose monitoring in pregnancy: a systematic review. Front Endocrinol (Lausanne) 2019; 10: 697
  • 23 Tartaglione L, di Stasio E, Sirico A. et al. Continuous glucose monitoring in women with normal OGTT in pregnancy. J Diabetes Res 2021; 2021: 9987646
  • 24 Sung JF, Kogut EA, Lee HC. et al. Correlation of continuous glucose monitoring profiles with pregnancy outcomes in nondiabetic women. Am J Perinatol 2015; 32 (05) 461-468
  • 25 Siegmund T, Rad NT, Ritterath C, Siebert G, Henrich W, Buhling KJ. Longitudinal changes in the continuous glucose profile measured by the CGMS in healthy pregnant women and determination of cut-off values. Eur J Obstet Gynecol Reprod Biol 2008; 139 (01) 46-52
  • 26 Secher AL, Madsen AB, Ringholm L. et al. Patient satisfaction and barriers to initiating real-time continuous glucose monitoring in early pregnancy in women with diabetes. Diabet Med 2012; 29 (02) 272-277
  • 27 Stewart ZA, Thomson L, Murphy HR, Beardsall K. A feasibility study of paired continuous glucose monitoring intrapartum and in the newborn in pregnancies complicated by type 1 diabetes. Diabetes Technol Ther 2019; 21 (01) 20-27
  • 28 Cordua S, Secher AL, Ringholm L, Damm P, Mathiesen ER. Real-time continuous glucose monitoring during labour and delivery in women with Type 1 diabetes - observations from a randomized controlled trial. Diabet Med 2013; 30 (11) 1374-1381
  • 29 Stenninger E, Lindqvist A, Aman J, Ostlund I, Schvarcz E. Continuous subcutaneous glucose monitoring system in diabetic mothers during labour and postnatal glucose adaptation of their infants. Diabet Med 2008; 25 (04) 450-454
  • 30 Nair BG, Dellinger EP, Flum DR, Rooke GA, Hirsch IB. A pilot study of the feasibility and accuracy of inpatient continuous glucose monitoring. Diabetes Care 2020; 43 (11) e168-e169
  • 31 Castorino K, Polsky S, O'Malley G. et al. Performance of the Dexcom G6 continuous glucose monitoring system in pregnant women with diabetes. Diabetes Technol Ther 2020; 22 (12) 943-947
  • 32 American Diabetes Association. 14. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43 (Suppl. 01) S183-S192
  • 33 Hamel MS, Kanno LM, Has P, Beninati MJ, Rouse DJ, Werner EF. Intrapartum glucose management in women with gestational diabetes mellitus: a randomized controlled trial. Obstet Gynecol 2019; 133 (06) 1171-1177
  • 34 Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol 2006; 195 (04) 1095-1099
  • 35 Dude AM, Niznik C, Peaceman AM, Yee LM. Evaluation of an intrapartum insulin regimen for women with diabetes. Obstet Gynecol 2020; 136 (02) 411-416
  • 36 Sosenko IR, Kitzmiller JL, Loo SW, Blix P, Rubenstein AH, Gabbay KH. The infant of the diabetic mother: correlation of increased cord C-peptide levels with macrosomia and hypoglycemia. N Engl J Med 1979; 301 (16) 859-862
  • 37 Bitar G, Bravo R, Pedroza C. et al. Permissive intrapartum glucose control: an equivalence randomized control trial (PERMIT). Am J Obstet Gynecol 2024; 231 (03) 355.e1-355.e11
  • 38 Modi A, Levy N, Hall GM. Controversies in the peripartum management of diabetes. Anaesthesia 2016; 71 (07) 750-755
  • 39 Duryea EL, Hawkins JS, McIntire DD. et al. A revised birth weight reference for the United States. Obstet Gynecol 2014; 124 (01) 16-22