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Large-For-Gestational-Age Neonates in Diabetes Mellitus Type 1 Pregnancy Treated With Continuous Subcutaneous Insulin Infusion: The Impact of Last Trimester A1C.

To the Editor: We read with interest the article in Your Journal written by Napoli1 concluding that for women with type 1 diabetes mellitus (T1DM), continuous subcutaneous insulin infusion (CSII) can be safely used during pregnancy and delivery of well-trained women. We would like to share our experiences regarding the predictors of neonatal birth weight in T1DM pregnancy treated with CSII. We retrospectively analyzed the data of 16 pregnant women with a T1DM duration of at least 2 years before pregnancy and treated with CSII (Medtronic MiniMed ParadigmVeo) for at least 3 months before conception. The median age at the time of conception was 28.5 years (23–36), median body mass index (BMI) was 23.1 kg/m2 (19–33), and median A1C was 6.5% (4.8–8.8). In the last trimester, the A1C was significantly lower (P, 0.05), with a median of 5.5% (4.6–7.1), and the median weight gain during pregnancy was 13 kg (4–20). All patients successfully delivered by caesarean section (standard practice for women with T1DM in the facility) without significant peripartal complications. The median week of delivery was 38 (35–39), and the median Appearance, Pulse, Grimace, Activity, and Respiration score was 10 (9–10). When corrected for gender and gestational age, 31% of newborns were large for gestational age and there was one preterm birth. Macrosomia was present in 19% of neonates. Among several analyzed parameters at the time of conception (BMI, body weight, A1C, and total, basal, and prandial insulin dose) and the same parameters in the last trimester (includingweight gain during pregnancy), only last trimester A1C was significant as a neonatal birth weight predictor. It had a strong positive correlation to neonatal birth weight (P 5 0.002, r 5 0.712), and in a linear regression analysis, its influence on birth weight was 65.3% (R2 5 0.653 and analysis of variance significance P 5 0.000). One of the most common adverse pregnancy outcomes arising from T1DM in pregnancy is LGA neonates.2 Przemyslaw et al highlighted in a meta-analysis of the 24 trials that pregnant women with T1DM treated with CSII were more likely to have an LGA infant than those who were treated with multiple daily injection.3 It was also reported that the difference in A1C values between the 2 arms decreased in the second trimester and disappeared in the last trimester when it was almost the same in both CSIIand MDI-treated patients. According to this observation, patients treated with CSII start with lower A1C, but at the end of pregnancy, they do not achieve better glucoregulation. Cyganek et al4 found that there was a linear relationship between the last trimester A1C and the risk of macrosomia, starting from values as low as 4.5%. As stated in the article we refer to,1 CSII allows flexible dosing adjustments so that more and more fertile women with pregestational diabetes are likely to become pregnant. However, despite high uptake levels of advanced diabetes technologies among pregnant women, rates of adverse fetal outcomes remain far above the target. Having in mind the huge influence of last trimester A1C on birth weight we found in cohort of patients with T1DM treated with CSII, an extra effort should bemade to persist with strict glyceamic control throughout the pregnancy and avoid LGA of neonates.