Type 1 Diabetes Mellitus and Pregnancy- Time Trends and Delivery Outcomes in Women With Concurrent Chronic Hypertension

Abstract

Objective: To examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes: maternal pre-pregnancy body mass index and gestational weight gain; treatment factors: glycemic control, insulin pump and continuous glucose monitor (CGM) use; and delivery outcomes: gestational age at delivery, birth weight and mode of delivery. Research Design and methods: We abstracted clinical data from the medical records of 700 pregnant women seeking care at the Joslin and Beth Israel Deaconess Medical Center Diabetes in Pregnancy Program from 2004-2017. Eligible women were >18 years old, had a singleton pregnancy, had clinically diagnosed type 1 diabetes mellitus and delivered a live birth during this time period. For each time period, means and percentages were calculated. P-values for trend were calculated using linear and logistic regression. Results: From 2004-2017, the use of insulin pumps and CGMs increased from 50% to 72.7%, and 0% to 39.9%, respectively (p<0.001). HbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (p=0.002). Excessive gestational weight gain increased (p=0.01). Gestation length also increased (p=0.01), as did vaginal deliveries (p=0.03). There were no change in birth weight percenties over time (p=0.77). and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged. Conclusion: Obstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA. Objective: To evaluate birth weight and other delivery outcomes among women with type 1 diabetes with and without chronic hypertension (cHTN), with cHTN treatment targeting blood pressure (BP) 110-129/65-79 mmHg. Research Design and methods: Clinical data were abstracted from medical records of 516 pregnancies among 393 women seeking prenatal care at Joslin Diabetes Center and Beth Israel Deaconess Medical Center’s Diabetes in Pregnancy Program (2004-2017). Means and percentages were calculated, along with t test or χ2 test. We used linear regression to compare birth weight percentiles in women with type 1 diabetes and cHTN to those with type 1 diabetes and no cHTN. Results: Type 1 diabetes and cHTN co-occurred in 51 (7.3%) of pregnancies. Per trimester, BP values were higher in pregnancies with type 1 diabetes and cHTN compared to pregnancies with type 1 diabetes and no cHTN (p<0.001). In pregnancies with type 1 diabetes and cHTN, women were older (33.4 vs. 31.6 years, p=0.01) and had greater prevalence of nephropathy (10.4% vs. 1.8% p<0.001). Gestational age at delivery and birth weight were lower in the cHTN group (36.5 weeks vs. 37.4 weeks, p=0.03) and (3482g vs. 3722g, p=0.03, respectively). There were no differences in birth weight percentiles and small for gestational age (SGA) was rare in both groups (2% vs. 1.7%, p=0.9). Conclusion: SGA was rare in pregnancies complicated by type 1 diabetes and cHTN, even when BP targets were110-129/65-79 mmHg. These findings may provide reassurance for reestablishing lower BP targets rather than adopting recent higher targets of 120-160/80-105 mmHg followed by ACOG (2013) and ADA (2017).