Technology advances in diabetes pregnancy: right technology, right person, right time

Abstract

This review outlines some of the extraordinary recent advances in diabetes technology, which are transforming the management of type 1 diabetes before, during and after pregnancy. It highlights recent improvements associated with use of continuous glucose monitoring (CGM) but acknowledges that neither CGM nor insulin pump therapy are adequate for achieving the pregnancy glucose targets. Furthermore, even hybrid closed-loop (HCL) systems that are clinically effective outside of pregnancy may not confer additional benefits throughout pregnancy. To date, there is only one HCL system, the CamAPS FX, with a strong evidence base for use during pregnancy, suggesting that the pregnancy benefits are HCL system specific. This is in stark contrast to HCL system use outside of pregnancy, where benefits are HCL category specific. The CamAPS FX HCL system has a rapidly adaptive algorithm and lower glucose targets with benefits across all maternal glucose categories, meaning that it is applicable for all women with type 1 diabetes, before and during pregnancy. For women of reproductive years living with type 2 diabetes, the relative merits of using non-insulin pharmacotherapies vs diabetes technology (dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors) are unknown. Despite the urgent unmet need and potential benefits, studies of pharmacotherapy and technology use are extremely limited in pregnant women with type 2 diabetes.

Keywords: Automated insulin delivery; Closed-Loop; Continuous glucose monitoring; Diabetes technology; Neonatal; Obstetric; Pregnancy; Review; Type 1 Diabetes; Type 2 Diabetes.

Fig. 1

(a) Serious adverse pregnancy outcomes (major congenital anomaly, stillbirth, neonatal death) according to early pregnancy HbA_1c categories, reproduced from the NPID Audit Report 2020 [5]. (b) Widening gaps in pregnancy preparation in type 1 and type 2 diabetes pregnancies, reproduced from the NPID Audit report 2021 and 2022 [14]. This figure is available as part of a downloadable slideset

Fig. 2

(a) Preterm birth (before 37 weeks’ gestation) rates in type 1 and type 2 diabetes pregnancies according to maternal HbA_1c categories. (b) LGA rates in type 1 and type 2 diabetes pregnancies according to maternal HbA_1c categories. Late pregnancy HbA_1c is defined as HbA_1c from 24 weeks’ gestation (reflecting antenatal glycaemia from approximately 16 to 20 weeks onwards). Reproduced from the NPID Audit report 2020 [5]. This figure is available as part of a downloadable slideset

Fig. 3

Serious adverse pregnancy outcomes (major congenital anomaly, stillbirth, neonatal death) according to CGM use during type 1 diabetes pregnancies in 2021–2022. CGM users had reduced odds for serious adverse pregnancy outcomes (OR 0.70 95% CI 0.53, 0.94; p=0.015). Reproduced from the NPID Audit report 2021 and 2022 [14]. This figure is available as part of a downloadable slideset