Continuous Subcutaneous Insulin Infusion versus Multiple Daily Injections of Insulin for the Management of Type 1 Diabetes Mellitus in Pregnancy: Association with Neonatal Chemical Hypoglycemia

Abstract

Objective We hypothesized that patients with type 1 diabetes mellitus (T1DM) who were managed during their pregnancy with a continuous subcutaneous insulin infusion (CSII) would have a lower incidence of neonatal hypoglycemia (NH) than patients managed with multiple daily injections (MDI) of insulin.

Study Design This was a retrospective cohort of 95 women with T1DM who delivered singleton, term neonates between 2007 and 2014. The primary outcome was incidence of NH (capillary plasma glucose ≤ 45 mg/dL) in the first 24 hours after birth.

Results The incidence of NH was 66.0% (62/95). The NH rate was significantly higher in women managed with CSII versus MDI (62 vs. 38%, p = 0.024). Neonates with NH had a higher birth weight (3,867 ± 658 vs. 3,414 ± 619 g, p = 0.002). When analyzing intrapartum glucose management, mothers of neonates with NH had significantly less time managed on an insulin infusion (median interquartile range 7 [3.5–30.5] vs. 17.5 [2.0–17.5] hours, p = 0.014). In multivariable analysis, only maternal body mass index (BMI) (p = 0.035) and time on an insulin infusion (p = 0.043) were significantly associated with NH.

Conclusion In our population of patients with T1DM, CSII was more prevalent in the NH group; however, when controlling for other factors, intrapartum glucose management and early maternal BMI were the only variables associated with NH.

Keywords

continuous subcutaneous insulin infusion pump - neonatal hypoglycemia - pregnancy - type 1 diabetes mellitus

Notes

This study was approved by the UCSD Human Research and Protections Program, IRB# 111310. The findings in this article were presented as a poster at the 35th Annual Meeting, The Pregnancy Meeting, San Diego, CA, February 2–7, 2015.

• References

• 1 Maahs DM, West NA, Lawrence JM, Mayer-Davis EJ. Epidemiology of type 1 diabetes. Endocrinol Metab Clin North Am 2010; 39 (3) 481-497
• 2 Centers for Disease Control and Prevention. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2011
• 3 American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 60: Clinical Management Guidelines for Obstetrician-Gynecologists: pregestational diabetes mellitus. Obstet Gynecol 2005; 105: 675-685
• 4 Buchanan TA, Kitzmiller JL. Metabolic interactions of diabetes and pregnancy. Annu Rev Med 1994; 45: 245-260
• 5 Philips AF, Dubin JW, Matty PJ, Raye JR. Arterial hypoxemia and hyperinsulinemia in the chronically hyperglycemic fetal lamb. Pediatr Res 1982; 16 (8) 653-658
• 6 Nold JL, Georgieff MK. Infants of diabetic mothers. Pediatr Clin North Am 2004; 51 (3) 619-637 , viii
• 7 Widness JA, Teramo KA, Clemons GK , et al. Temporal response of immunoreactive erythropoietin to acute hypoxemia in fetal sheep. Pediatr Res 1986; 20 (1) 15-19
• 8 Adamkin DH ; Committee on Fetus and Newborn. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics 2011; 127 (3) 575-579
• 9 Cornblath M, Hawdon JM, Williams AF , et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics 2000; 105 (5) 1141-1145
• 10 Cordero L, Treuer SH, Landon MB, Gabbe SG. Management of infants of diabetic mothers. Arch Pediatr Adolesc Med 1998; 152 (3) 249-254
• 11 Cowett RM, Susa JB, Giletti B, Oh W, Schwartz R. Glucose kinetics in infants of diabetic mothers. Am J Obstet Gynecol 1983; 146 (7) 781-786
• 12 Aucott SW, Williams TG, Hertz RH, Kalhan SC. Rigorous management of insulin-dependent diabetes mellitus during pregnancy. Acta Diabetol 1994; 31 (3) 126-129
• 13 Wollitzer AD, Zisser H, Jovanovic L. Insulin pumps and their use in pregnancy. Diabetes Technol Ther 2010; 12 (Suppl. 01) S33-S36
• 14 Pickup JC, Keen H, Parsons JA, Alberti KG, Rowe AS. Continuous subcutaneous insulin infusion: improved blood-glucose and intermediary-metabolite control in diabetics. Lancet 1979; 1 (8129) 1255-1257
• 15 Lenhard MJ, Reeves GD. Continuous subcutaneous insulin infusion: a comprehensive review of insulin pump therapy. Arch Intern Med 2001; 161 (19) 2293-2300
• 16 Mukhopadhyay A, Farrell T, Fraser RB, Ola B. Continuous subcutaneous insulin infusion vs intensive conventional insulin therapy in pregnant diabetic women: a systematic review and metaanalysis of randomized, controlled trials. Am J Obstet Gynecol 2007; 197 (5) 447-456
• 17 Farrar D, Tuffnell DJ, West J. Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes. Cochrane Database Syst Rev 2007; (3) CD005542
• 18 Gabbe SG, Holing E, Temple P, Brown ZA. Benefits, risks, costs, and patient satisfaction associated with insulin pump therapy for the pregnancy complicated by type 1 diabetes mellitus. Am J Obstet Gynecol 2000; 182 (6) 1283-1291
• 19 Petrovski G, Dimitrovski C, Bogoev M, Milenkovic T, Ahmeti I, Bitovska I. Is there a difference in pregnancy and glycemic outcome in patients with type 1 diabetes on insulin pump with constant or intermittent glucose monitoring? A pilot study. Diabetes Technol Ther 2011; 13 (11) 1109-1113
• 20 Combs CA. Continuous glucose monitoring and insulin pump therapy for diabetes in pregnancy. J Matern Fetal Neonatal Med 2012; 25 (10) 2025-2027
• 21 Kernaghan D, Farrell T, Hammond P, Owen P. Fetal growth in women managed with insulin pump therapy compared to conventional insulin. Eur J Obstet Gynecol Reprod Biol 2008; 137 (1) 47-49
• 22 Grunberger G, Bailey TS, Cohen AJ , et al; AACE Insulin Pump Management Task Force. Statement by the American Association of Clinical Endocrinologists Consensus Panel on insulin pump management. Endocr Pract 2010; 16 (5) 746-762
• 23 Misso ML, Egberts KJ, Page M, O'Connor D, Shaw J. Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus. Cochrane Database Syst Rev 2010; (1) CD005103
• 24 Pickup J, Mattock M, Kerry S. Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomised controlled trials. BMJ 2002; 324 (7339) 705
• 25 Bruttomesso D, Bonomo M, Costa S , et al; Italian Group for Continuous Subcutaneous Insulin Infusion in Pregnancy. Type 1 diabetes control and pregnancy outcomes in women treated with continuous subcutaneous insulin infusion (CSII) or with insulin glargine and multiple daily injections of rapid-acting insulin analogues (glargine-MDI). Diabetes Metab 2011; 37 (5) 426-431
• 26 Talaviya PA, Saboo BD, Joshi SR , et al. Pregnancy outcome and glycemic control in women with type 1 diabetes: a retrospective comparison between CSII and MDI treatment. Diabetes Metab Syndr 2013; 7 (2) 68-71
• 27 Chen R, Ben-Haroush A, Weismann-Brenner A, Melamed N, Hod M, Yogev Y. Level of glycemic control and pregnancy outcome in type 1 diabetes: a comparison between multiple daily insulin injections and continuous subcutaneous insulin infusions. Am J Obstet Gynecol 2007; 197 (4) 404.e1-404.e5
• 28 Cypryk K, Kosiński M, Kamińska P, Kozdraj T, Lewiński A. Diabetes control and pregnancy outcomes in women with type 1 diabetes treated during pregnancy with continuous subcutaneous insulin infusion or multiple daily insulin injections. Pol Arch Med Wewn 2008; 118 (6) 339-344
• 29 Lepercq J, Abbou H, Agostini C , et al. A standardized protocol to achieve normoglycaemia during labour and delivery in women with type 1 diabetes. Diabetes Metab 2008; 34 (1) 33-37
• 30 Kline GA, Edwards A. Antepartum and intra-partum insulin management of type 1 and type 2 diabetic women: impact on clinically significant neonatal hypoglycemia. Diabetes Res Clin Pract 2007; 77 (2) 223-230
• 31 Ryan EA, Al-Agha R. Glucose control during labor and delivery. Curr Diab Rep 2014; 14 (1) 450
• 32 Carron Brown S, Kyne-Grzebalski D, Mwangi B, Taylor R. Effect of management policy upon 120 Type 1 diabetic pregnancies: policy decisions in practice. Diabet Med 1999; 16 (7) 573-578
• 33 Barrett HL, Morris J, McElduff A. Watchful waiting: a management protocol for maternal glycaemia in the peripartum period. Aust N Z J Obstet Gynaecol 2009; 49 (2) 162-167
• 34 Williams AF. Hypoglycaemia of the newborn: a review. Bull World Health Organ 1997; 75 (3) 261-290