Achieving better outcomes in pregnancies complicated by type 1 and type 2 diabetes mellitus.

BACKGROUND: Pregnancy in type 1 and type 2 diabetes mellitus (DM) is associated with an increased rate of adverse outcomes for both mother and fetus.

OBJECTIVE: This article reviews the data available on achieving better outcomes in pregnancies complicated by DM.

METHODS: Background materials for this article were gathered based on a PubMed search of English-language articles (up to and including August 2007) using the search terms diabetes mellitus, pregnancy, glycemic control, mortality, and morbidity. This review article was based on a presentation given at a satellite symposium entitled "Realising the Value of Modern Insulins: Reaching Further with Rapid-Acting Insulin Analogues" that was convened during the XIXth World Diabetes Congress, December 3, 2006, in Cape Town, South Africa.

RESULTS: There is clear evidence that optimized metabolic control, from preconception through pregnancy, can reduce the risk of maternal and fetal complications in women with DM. The risk of fetal congenital abnormalities in pregnant women with DM is intricately related to the level of glycemic control in early pregnancy; thus, strict metabolic targets as close to normal glycosylated hemoglobin (HbA1c) (ie, 4.0%-6.0%) as possible are recommended. However, these HbA1c and postprandial plasma glucose targets are challenging for the physician and the patient. The rapid-acting insulin analogues, insulin aspart and insulin lispro, may be useful because they can reduce postprandial hyperglycemia without increasing the risk for hypoglycemia and even provide a small improvement in HbA1c compared with regular human insulin. In a recent, prospective, randomized controlled study of pregnant women with type 1 DM (N=322), maternal hypoglycemia, metabolic control, and tolerability, including perinatal outcomes, were compared between those randomized to mealtime insulin aspart or human insulin. The results from this study suggest that insulin aspart is at least as effective and well tolerated as human insulin in basal-bolus therapy with neutral protamine Hagedorn insulin. Overall, 80% of study participants in both groups achieved HbA1c levels<or=6.5% in the second trimester. In addition, insulin aspart was associated with lowered postprandial blood glucose levels, as well as reduced risk of hypoglycemia, suggesting that it may offer clinical advantages in this population.

CONCLUSIONS: Women with DM who are of reproductive age should be identified as members of a high-risk group. Access to specialized prepregnancy clinics should be made available where their DM can be intensively managed throughout pregnancy by a combined obstetrical/endocrine multidisciplinary team. Use of multiple insulin injection regimens, including use of insulin aspart during pregnancy, is both well tolerated and effective and may offer some benefits with respect to postprandial glycemic control.