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Teamwork Enhances Glucose Control in Diabetics : A study of team-managed insulin targeting found a low rate of diabetes-related obstetric complications.


 

SAN FRANCISCO — Pregnancy outcomes for women with diabetes who maintain excellent glucose control during their pregnancy are very good, and are similar to those seen in the general population, according to the results of a retrospective study.

The study, conducted by the high-risk obstetrics/endocrinology clinic at the Nebraska Medical Center, Omaha, found a low rate of diabetes-related obstetric complications among a group of 100 women who attended the clinic during their pregnancies.

The clinic has used a team approach, incorporating intensive insulin and specific targets, since 1997. That approach “can result in excellent glucose control in at least half of patients, with overall maternal and fetal outcomes similar to” those in the general population, Dr. Kara Meinke Baehr said in a poster presented at the annual meeting of the Endocrine Society. The team includes perinatologists, endocrinologists, certified diabetes educators, registered dietitians, a social worker, and a translator.

Dr. Meinke Baehr of the Nebraska Medical Center and her colleagues reviewed the records of 100 women whose pregnancies were managed at the clinic from 1997 to 2006. Fetal outcomes were compared with the Nebraska 2004 Vital Statistics report.

The mean age at enrollment in the clinic was 29 years; the mean prepregnancy body mass index was 32 kg/m

More than a third of the women (36%) had type 1 diabetes; 26% had type 2 diabetes; 26% had gestational diabetes managed with insulin; and 12% had gestational diabetes managed by diet.

Women with types 1 and 2 diabetes significantly improved their blood glucose levels during the second and third trimesters of their pregnancies. At 8 weeks, only 25% had a hemoglobin A1c (HbA1c) value of less than 7%. That number rose to 80% by week 16 and to 90% by week 24; it then dropped back to 80% by week 32.

By the second half of pregnancy, about half of the cohort was meeting the goal of an HbA1c value of 6% or less, a significant improvement from the first trimester.

Maternal complications during pregnancy included retinopathy (6%), proteinuria (38%), and pre-eclampsia (17%). There were 104 hospitalizations, more than half of which were for glucose control. One woman was admitted 10 times.

Insulin regimens were used in 115 of the 127 pregnancies (90%). At the time of delivery, 43% were taking four injections per day; 2% were taking one insulin injection per day; 22% were taking two injections per day; and 3% were taking three injections per day. In all, 20% were using an insulin pump.

There were 127 pregnancies among these women over the study period, including 121 live births with two sets of twins. Most of the deliveries (71%) were by cesarean section; the rest were vaginal.

The mean gestational age was 37 weeks. Apgar scores were good, with a mean of 7.4 at 1 minute and 8.5 at 5 minutes. The mean birth weight was 3,479 grams; 28% of the infants were macrosomic. Overall, 35% of the infants required a stay in the neonatal intensive care unit (mean length of stay, 16 days).

The rate of birth trauma was 2%; traumas included Erb's palsy and shoulder dystocia. The rate of birth defects was 7%. Such defects included one schizencephaly, one tracheoesophageal fistula, one transposition of the great vessels, one polydactyly, and two cases of patent ductus arteriosus.

All rates were lower than those in the 2004 Nebraska state report, but comparisons can't be drawn because of the small study sample, Dr. Meinke Baehr noted.

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