فناوری های اضطراری برای مدیریت دیابت نوع 1 در بارداری Emerging Technologies for the Management of Type 1 Diabetes in Pregnancy

Introduction Pregnancies in women with type 1 diabetes continue to be at increased risk of potentially serious complications [1]. The risk of these complications can be attenuated by tight glycaemic control preconception and throughout pregnancy [2, 3]. While tight glycaemic control is central to the management of type 1 diabetes in pregnancy, achieving the targets necessary to reduce pregnancy-related complications remains challenging. Many physiologic changes throughout pregnancy as well as other unique circumstances such as labour and delivery and the postpartum period make frequent insulin adjustments and close follow-up necessary [4, 5]. Despite specialised interdisciplinary clinics, and advances in the treatment of women with type 1 diabetes, a large contemporary cohort study in the UK found that most women did not achieve optimal glycaemic control [6••]. More specifically, only 16 and 40% of women with type 1 diabetes in early and late pregnancy respectively met guideline-suggested haemoglobin A1c (HbA1c) targets of less than 48 mmol/mol (6.5%) [6••]. This nationwide study did note improvement in some pregnancy outcomes, namely a 2.5-fold reduction in stillbirths; however, one in two babies still experienced complications related to maternal hyperglycaemia, namely large for gestational age, preterm delivery and/or admission to neonatal intensive care units. It also highlights the substantial contribution of between clinic variation suggesting much room for improvement in the way we care for women with type 1 diabetes before and during pregnancy. The use of technology in the treatment of women with diabetes may help bridge the gap between current and optimal glycaemic control in pregnancy with the goal of improving outcomes for mother and infant. This review will discuss emerging technologies available in the management of type 1 diabetes in pregnancy and their effect on glycaemic control and pregnancy outcomes. More specifically, we will review the use of continuous glucose monitoring (CGM) technologies, the insulin pump and sensor-integrated insulin delivery in care of women with type 1 diabetes in pregnancy. Continuous Glucose Monitoring CGM uses a sensor inserted subcutaneously to record glucose concentrations in the interstitial fluid generating almost 300 glucose measurements per day. It communicates the measured glucoses to a mobile phone, smartwatch or stand-alone receiver device via Bluetooth. The CGM sensor, which is disposable, is typically changed weekly, and the transmitter duration is approximately 12 months depending on the system. The accuracy of CGM has improved substantially over the past 5–10 years with some systems now considered accurate enough to enable pre-meal bolusing without the need for confirmation with capillary glucose testing. However, most devices, other than the Flash glucose monitor, still require calibration with capillary glucose testing two to four times a day [7]. The Flash glucose monitoring system is factory calibrated and is considered a replacement for capillary glucose testing rather than a continuous glucose monitoring system as it lacks hypoglycaemia and hyperglycaemia alerts and alarms and is not integrated with insulin delivery. CGM yields rich glucose data that can be used to manage insulin in real time, examine glycaemic trends, and study glucose metabolism [8]. Outside of pregnancy, CGM has been shown to improve glucose control in selected populations who are motivated to wear the device regularly (at least 6 days per week) [9]. Further evidence suggests that the use of CGM can also reduce hypoglycaemia [10]. Various studies have highlighted both benefits and drawbacks of the use of this tool in women with type 1 diabetes in pregnancy.