Care for Women with Pre-Existing Diabetes During Pregnancy

00:00:00: Diabetes Insights, Breakthroughs and Innovators.

00:00:04: The EASD TV podcast

00:00:07: from the

00:00:07: annual meeting of the European Association for the Study of Diabetes.

00:00:13: Hello again!

00:00:14: Now we've seen a lot guidelines talked about and launched at this particular Congress but one of them most important is the Guidelines on Pregnancy.

00:00:25: It's something that in the past, there are multiple guidelines from all sorts of different people.

00:00:30: But I think at last what we're going to see is like one ring to rule them all a definitive set of guidelines and We have a cast of four to tell me all about it And i will introduce him To you.

00:00:45: let's start with genica wike off on the university of michigan.

00:00:49: uh...we Have annunziata la polar from italy We have Linda Barber from the University of Colorado, and finally last but not least we have Rosa Corcoi from Barcelona.

00:01:04: So let's start with you tell me who was involved in doing this set of guidelines?

00:01:09: And why are they important?

00:01:12: so The Endocrine Society and the European society for endocrinology both did a joint guideline.

00:01:19: In addition to two of them who were leading this guideline, there are a number other organizations including the American College of Obstetrics and Gynecology as well others that endorsed guidelines.

00:01:34: It's very important I think for standardization in how we think about diabetes in pregnancy.

00:01:43: The field has long been struggling with the fact that there are different diagnoses, different diagnostic criteria and therapeutic approaches And it muddles care as well as research in the area.

00:01:57: Okay Well let's do this in order.

00:01:59: So first of all pre-conception.

00:02:04: Even though fifty percent of pregnancies are unplanned

00:02:07: planning

00:02:08: in people living with diabetes, are the type one or type two is really important for preconception?

00:02:14: Absolutely.

00:02:16: So there was an absolutely fabulous meta-analysis by Wahhabi in twenty twenty and it showed that there's a seventy one percent reduction in congenital malformations when pregnancies...when patients had the opportunity to get preconception care It reduced many of the poor outcomes.

00:02:35: we see pregnancies complicated by diabetes, and one of the key important points of understanding from a policy standpoint for preconception care is that multiple studies have shown it's cost-effective.

00:02:50: And there are actually meta-analysis showing its cost effective.

00:02:55: Oh, I can't remember the year but Peterson's study suggested that there would be savings in the billions of dollars if preconception care were universal.

00:03:07: Gosh!

00:03:09: So strong recommendation on pre-conception at care?

00:03:13: Our guidelines actually don't specifically recommend preconception a grade format.

00:03:24: So what we had to select was specific questions, and the specific question that we chose is should there be screening for pregnancy intent?

00:03:35: Because where we fail.

00:03:36: everybody recommends pre-conception care but when we fail it's getting people too pre-consumptioned.

00:03:49: just come into your office and aren't specifically saying they're planning a pregnancy.

00:03:53: We want to capture those people who don't plan their pregnancies, make sure that you understand the importance of preconception care so we can get people to pre-conception care.

00:04:02: What about nutrition in pregnancy?

00:04:05: Because it's always such an authority subject should people eat for two?

00:04:11: what specific nutrients do they have if they are living with diabetes?

00:04:16: Yes To have a correct nutrition during pregnancy is important to have safe pregnancy in terms of fetal growth and so on, and on fetal complications.

00:04:27: And this term it's important.

00:04:29: the amount of carbohydrates and calories that depends from pre-pregnancy body mass index for these women.

00:04:37: Unfortunately there are no strong studies in literature.

00:04:42: So, we cannot say what is the best amount of carbohydrates that women must eat to have a safe pregnancy.

00:04:53: It's very important for us to have studies which can tell us about what is best.

00:05:00: I guess people will be worried about macrosomia and so perhaps eat less.

00:05:07: Pregnancy is a time of just acute anxiety, even if you aren't living with diabetes.

00:05:12: So if you have the double whammy it's really difficult.

00:05:17: Linda, tell me about the use of therapeutics and what guidelines say about that?

00:05:22: Well there were two topics we thought would be very helpful to try and address because they are very controversial globally And one is the use of metformin in pregnancy, and the other ones are GLP-ones in pregnancy.

00:05:36: In which so many women come to us on a GLP One for weight loss and then conceive on

00:05:42: them.".

00:05:43: So those were two issues that we had some data—we had most of the data with metformins.

00:05:51: Metformin is used globally.

00:05:53: it's used outside of pregnancy —the number one drug used for diabetes.

00:05:58: The question we wanted to ask is, Is it optimal?

00:06:04: To add metformin in patients with type two diabetes already on insulin.

00:06:10: And there's a lot of excitement about using metformins because its easy-to use.

00:06:15: but when looked at all the randomized controlled studies and outcomes although metformine was shown decrease large for gestational age babies There were also some data suggesting that cause nutrient restriction and one study could increase the risk for small gestational age babies.

00:06:34: And at least in some mechanistic data, in non-human primates are monkey cousins of which you can study this very carefully in the fetus these mother monkeys that took metformin at levels that were seen in pregnancy and also levels obtained from the fetuses similar to pregnancy.

00:06:55: These baby monkeys unfortunately had decreased skeletal muscle growth, and problems with decrease heart development in kidney development.

00:07:05: So this was an area where we thought there were some benefits but also long-term risks that could increase the risk of childhood obesity.

00:07:22: So it came up with a conclusion that we did not recommend routinely the use of metformin in pregnancy, another area where we need long-term studies.

00:07:31: And then other areas which really wanted to try and delve into was the use GLP ones since so many women are on them.

00:07:41: Ironically because they lose weight?

00:07:42: Absolutely!

00:07:44: So many people became pregnant but didn't even realize.

00:07:49: And so many women want to continue those GLP-ones because it's been shown that once you stop them, you have rebound weight gain.

00:08:01: The data unfortunately was very limited and extremely conditional because there were just not the database in which we could look at exposure during the first trimester to determine whether they're any negative effects of a GLP one in pregnancy.

00:08:19: GLP-ones are very large proteins.

00:08:21: They probably do not cross the placenta, but there are some receptors on the placentia and I think that at this point we could not recommend GLP one use.

00:08:32: We recommended they stop before pregnancy in order to establish good glycemic control with another agent since stopping them can cause rebound hyperglycemia At a time when the baby's organs or forming.

00:08:46: However, I think more studies may actually demonstrate some safety in the first trimester but we just don't have that data yet.

00:08:57: One good thing... And

00:08:57: not very difficult for women isn't it?

00:08:59: Because a first thing they want to know if they've conceived unexpectedly while taking their GOP ones is what's this going to do with baby?

00:09:08: Exactly

00:09:09: and there are no data incriminating these agents cause malformations, it's just we don't have enough data.

00:09:17: And the data unfortunately can extrapolate in animals because these animals didn't eat one of GLP-one and so there was growth restriction probably because the animal starved.

00:09:27: Um...and women are very concerned about rebound weight gain once they stop a GLP One.

00:09:33: but at this point we felt that its'so important to have time to transition someone off a GL P-One glucose control during the time that babies organs are forming.

00:09:45: That stopping it prior to pregnancy, transitioning them into an agent is at least At this point The best thing to do rather than stopping It.

00:09:54: and their glucose is going up before we have a chance To actually control their diabetes.

00:09:58: And that really speaks again to your preconception.

00:10:01: care just how critically important?

00:10:04: So I think most people don't realize that the heart is formed before most people actually realize they're pregnant.

00:10:11: And the critical thing is that the most common congenital malformation you see in an infant of a mother with diabetes, it's heart defect.

00:10:19: and because the heart has formed so early in pregnancy if your trying to control blood sugars after someone figures out their pregnant You've probably missed the window to reduce the congenial malformations we seen at the heart.

00:10:32: Now there are other organs that form later.

00:10:35: Tough message for mothers-to be

00:10:38: It is.

00:10:39: So let me just go to you Rosa, talk about technology because there's been a debate about CGM use and what technologies should be used.

00:10:50: where did the guidelines come out on technology?

00:10:53: Okay we have addressed several points.

00:10:56: The first one that they use of CGM in persons with diabetes type-to-diabetes in pregnancy.

00:11:03: right now the CGM uses well established for type I not for type two.

00:11:09: And we have concluded that there is no clear evidence to support it.

00:11:13: and the recommendations are to use either CGM or self-monitoning of blood glucose.

00:11:20: And this is because there's no clear evidence of superiority, not from randomized controlled trials.

00:11:28: There are few of them and a number of patients with old systems so you can't imagine what could happen to new systems.

00:11:37: There're studies going on but results aren't available... Of course we have gone into indirect evidences.

00:11:45: for example pregnant women with type one, it's okay but difficult to extrapolate because they are not exactly the same.

00:11:53: The drivers of outcomes are different.

00:11:56: so no good extrapolation from there.

00:11:59: We also have information for patients with type II diabetes outside pregnancies.

00:12:04: CGM is beneficial, but there are also difficulties for extrapolating them the results because in pregnancy we mean not using CGM or using cell monitoring of blood glucose four times per day and this was not the case in studies outside pregnancy.

00:12:23: so supportive evidence that difficult to extrapolate.

00:12:27: Also, some evidence indirect of using CGM in real life and it appeared to be beneficial.

00:12:34: but the problem is that there may be hidden bias between women using and not using CGM.

00:12:41: So overall supportive evidence no clear evidence of superiority plus addition concern.

00:12:49: according to numbers with type two this cost would probably higher than being allocated right now to type one, and this probably is not acceptable.

00:13:01: Meanwhile we don't have a clear evidence of

00:13:04: superiority.".

00:13:05: So it's really pointing out.

00:13:06: there are so many gaps in evidence.

00:13:08: I always think that pregnant women get the fluffy end-of-the lollipop.

00:13:14: they're excluded from so many trials And yet... There was a desperate need!

00:13:22: Before we come up with an important point afterwards, because what happens is we think about women before.

00:13:31: We think about during and we think of them as a birth then run away to leave in general so what happens afterward?

00:13:39: In terms of breastfeeding or advice for subsequent pregnancy?

00:13:46: So, you're absolutely correct.

00:13:48: In the United States there's several small studies at various institutions that show very poor follow-up postpartum.

00:13:56: There is often a Postpartum visit six weeks but reestablishment of diabetes care in first year are often low and women struggle with breastfeeding.

00:14:10: specifically Women with diabetes have much lower rates of breastfeeding, and part of that is because they've increased complications that will interrupt their breastfeeding.

00:14:19: But part of it also hyper-and specifically hypoglycemia.

00:14:24: in the postpartum period immediately after birth insulin requirements drop dramatically And there's some question of association about breastfeeding with hypoglycemia.

00:14:37: so many women fear hypoglycaemia and stop breastfeeding because of hypoglycemia.

00:14:44: And that, of course is detrimental in some ways to both the mom's health and baby's health.

00:14:50: We always want to encourage breastfeeding.

00:14:53: The other really important point about postpartum and interpartum periods Is often pre-conception for next pregnancy.

00:15:04: Most women who just had a baby, it's pretty effective contraceptive not.

00:15:08: You think why did I ever do this?

00:15:12: So there is actually data that women who have had pregnancy are more likely to have another pregnancy and so its very important thing both for the health of next pregnancy but also for cardiovascular postpartum care to lower her cardiovascular risk factors, even if she's not planning another pregnancy.

00:15:40: She needs that for her own health as well and so ignoring the post-partum woman is at our detriment.

00:15:48: The other thing...the other group that has often very missed in this Is women with pregnancy loss.

00:15:55: Women with pregnancy laws are suffering many.

00:15:59: They're suffering a trauma And they may not They may not take care of themselves as well because of that trauma, and they are the least likely to get postpartum diabetes care.

00:16:15: Because their OB-GYN MFMs aren't always thinking about reestablishing that.

00:16:24: It's really an unfortunate area to get them back.

00:16:27: So

00:16:27: that brings me back to you, Linda at this postpartum period and the therapeutics in that post-partum because people always worry what can I take if i am breastfeeding?

00:16:39: so I think the point that Jen was making is so important... You would thank women who had diabetes Would be in a position where they would be able to plan their next pregnancy?

00:16:50: Know exactly when they were going get pregnant, but we actually see often very short interpregnancy intervals Where women don't realize that They can get pregnant again and the chronologists are not The best at providing contraception and explaining How quickly women can't get pregnant.

00:17:08: Again even if there breastfeeding And often you're put on agents so they can't beat quit that they can't take in pregnancy, and so the cycle continues without good preconception care.

00:17:21: And

00:17:21: of course postpartum is a time when people pile on their weight?

00:17:24: Absolutely!

00:17:25: So one good thing has recently been demonstrated at least semi-glutide—a very popular GLP-one does not appear to cross into breast milk.

00:17:37: And it is so imperative, especially with so many women with type two diabetes and type one diabetes without obesity to try lose that weight postpartum be at a better BMI the next pregnancy.

00:17:51: That this at least as an opportunity for women to get back on in agent but has been so beneficial.

00:17:57: um...and It's important then these women are contraceptive So they can go into their next pregnancy out of lower-weight more prepared and not have these short pregnancy intervals, which actually increase their risk in a subsequent pregnancy of adverse outcomes.

00:18:16: So having the endocrinologist and OB-GYN and primary care that transition process is so critical.

00:18:27: So just the same cycle of lack of preconception that care doesn't keep occurring.

00:18:33: This is a hugely important area and I'm delighted you have got these guidelines now, but they do point out what a lack of information there.

00:18:49: Thank you.

00:18:53: And there will be more from EASD TV very

00:19:18: soon!