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Meta-Analysis
. 2016 May 4;2016(5):CD008540.
doi: 10.1002/14651858.CD008540.pub4.

Different intensities of glycaemic control for pregnant women with pre-existing diabetes

Philippa Middleton  1 , Caroline A Crowther, Lucy Simmonds
Affiliations
Meta-Analysis

Different intensities of glycaemic control for pregnant women with pre-existing diabetes

Philippa Middleton et al. Cochrane Database Syst Rev. .

Abstract

Background: The optimal glycaemic control target in pregnant women with pre-existing diabetes is unclear, although there is a clear link between high glucose concentrations and adverse birth outcomes.

Objectives: To assess the effects of different intensities of glycaemic control in pregnant women with pre-existing type 1 or type 2 diabetes.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016) and planned to search reference lists of retrieved studies.

Selection criteria: We included randomised controlled trials comparing different glycaemic control targets in pregnant women with pre-existing diabetes.

Data collection and analysis: Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

Main results: We included three trials, all in women with type 1 diabetes (223 women and babies). All three trials were at high risk of bias due to lack of blinding, unclear methods of randomisation and selective reporting of outcomes. Two trials compared very tight (3.33 to 5.0 mmol/L fasting blood glucose (FBG)) with tight-moderate (4.45 to 6.38 mmol/L) glycaemic control targets, with one trial of 22 babies reporting no perinatal deaths orserious perinatal morbidity (evidence graded low for both outcomes). In the same trial, there were two congenital anomalies in the very tight, and none in the tight-moderate group, with no significant differences in caesarean section between groups (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.49 to 1.73; evidence graded very low). In these two trials, glycaemic control was not significantly different between the very tight and tight-moderate groups by the third trimester, although one trial of 22 women found significantly less maternal hypoglycaemia in the tight-moderate group.In a trial of 60 women and babies comparing tight (≤ 5.6 mmol/L FBG); moderate (5.6 to 6.7 mmol/L); and loose (6.7 to 8.9 mmol/L) glycaemic control targets, there were two neonatal deaths in the loose and none in the tight or moderate groups (evidence graded very low). There were significantly fewer women with pre-eclampsia (evidence graded low), fewer caesarean sections (evidence graded low) and fewer babies with birthweights greater than 90th centile (evidence graded low) in the combined tight-moderate compared with the loose group.The quality of the evidence was graded low or very low for important outcomes, because of design limitations to the studies, the small numbers of women included, and wide confidence intervals crossing the line of no effect. Many of the important outcomes were not reported in these studies.

Authors' conclusions: In a very limited body of evidence, few differences in outcomes were seen between very tight and tight-moderate glycaemic control targets in pregnant women with pre-existing type 1 diabetes, including actual glycaemic control achieved. There is evidence of harm (increased pre-eclampsia, caesareans and birthweights greater than 90th centile) for 'loose' control (FBG above 7 mmol/L). Future trials comparing interventions, rather than glycaemic control targets, may be more feasible. Trials in pregnant women with pre-existing type 2 diabetes are required.

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Conflict of interest statement

None known.

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 1 Caesarean section.
1.2
1.2. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 2 Perinatal mortality.
1.3
1.3. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 3 Serious perinatal morbidity.
1.4
1.4. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 4 Congenital fetal anomaly.
1.5
1.5. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 5 Pregnancy‐induced hypertension.
1.6
1.6. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 6 Chronic hypertension: not prespecified.
1.7
1.7. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 7 Glycaemic control ‐ Self‐monitored blood glucose (mean, mmol/L).
1.8
1.8. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 8 Glycaemic control ‐ Self‐monitored blood glucose tests/day.
1.9
1.9. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 9 Glycaemic control ‐ HbA1c (%): first trimester.
1.10
1.10. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 10 Glycaemic control ‐ HbA1c (%): second trimester.
1.11
1.11. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 11 Glycaemic control ‐ HbA1c (%): third trimester.
1.12
1.12. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 12 Glycaemic control ‐ Mean preprandial glucose (mmol/L).
1.13
1.13. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 13 Glycaemic control ‐ Mean postprandial glucose (mmol/L).
1.14
1.14. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 14 Glycaemic control ‐ Below FBG threshold (% days).
1.15
1.15. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 15 Hypoglycaemic episodes ‐ > 1 subjective (% of days): not prespecified.
1.16
1.16. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 16 Gestational weight gain (kg/week).
1.17
1.17. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 17 Fetal distress: not prespecified.
1.18
1.18. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 18 Gestational age at birth (weeks).
1.19
1.19. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 19 Birthweight (g).
1.20
1.20. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 20 Apgar score.
1.21
1.21. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 21 Asphyxia: not prespecified.
1.22
1.22. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 22 Neonatal hypocalcaemia.
1.23
1.23. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 23 Neonatal hypomagnesaemia: not prespecified.
1.24
1.24. Analysis
Comparison 1 Very tight versus tight‐moderate glycaemic control, Outcome 24 Maternal hospitalisation (days).
2.1
2.1. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 1 Pre‐eclampsia.
2.2
2.2. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 2 Caesarean section.
2.3
2.3. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 3 Perinatal mortality.
2.4
2.4. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 4 Transient maternal hypertension.
2.5
2.5. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 5 Hypoglycaemic epispodes ‐ first half of pregnancy: not prespecified.
2.6
2.6. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 6 Large‐for‐gestational age (birthweight > 90th centile).
2.7
2.7. Analysis
Comparison 2 Tight versus moderate glycaemic control, Outcome 7 Respiratory distress syndrome.
3.1
3.1. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 1 Pre‐eclampsia.
3.2
3.2. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 2 Caesarean section.
3.3
3.3. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 3 Perinatal mortality.
3.4
3.4. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 4 Transient maternal hypertension.
3.5
3.5. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 5 Hypoglycaemic episodes ‐ in first half of pregnancy: not prespecified.
3.6
3.6. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 6 Large‐for‐gestational age (birthweight > 90th centile).
3.7
3.7. Analysis
Comparison 3 Tight‐moderate versus loose glycaemic control, Outcome 7 Respiratory distress syndrome.
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Update of

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References to other published versions of this review

Middleton 2010
    1. Middleton P, Crowther CA, Simmonds L, Muller P. Different intensities of glycaemic control for pregnant women with pre‐existing diabetes. Cochrane Database of Systematic Reviews 2010, Issue 9. [DOI: 10.1002/14651858.CD008540.pub2] - DOI - PubMed
Middleton 2012
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