Normalization of pregnancy outcome in pregestational diabetes through functional insulin treatment and modular outpatient education adapted for pregnancy

Pregnancy outcomes for diabetic women reflect how well glycemia is controlled. Functional insulin treatment (FIT), which distinguishes between basal, meal-related, and correctional insulin and promotes flexible eating, isthe principal element of the structured outpatient group educational scheme used in managing 76 consecutive pregnancies in 59 women with pregestational diabetes, 54 of whom had type I diabetes, Controls included a historical series of diabetic pregnancies, a retrospective group of nondiabetic pregnancies, and population-based data for all newborn infants registered in Austria during the study period. The historical control group of six women had had at least one diabetic pregnancy before and after the introduction of FIT. Patient training used one-on-one patient counseling and structured group teaching modules recommended by a diabetes care team. Treatment was based on lowering target blood glucose levels and doubling the frequency of self-monitoring of blood glucose compared with the nonpregnant state. Weekly contact was considered optimal. Ultrasound screening for malformations and fetal echocardiography were carried out at 20 weeks' gestation, and ultrasound was done biweekly from 28 weeks of gestation onward. In general, women were admitted only after labor began. Glycosylated hemoglobin levels were 113% of the mean value for nondiabetic, nonpregnant women in the last trimester, and self-monitored blood glucose averaging 5.6 mmol/L was achieved throughout all FIT pregnancies. Severe hypoglycemia complicated 14 pregnancies. The gestational age at delivery averaged 39.2 weeks, with 5% of cases less than 37 weeks, and the mean birth weight was 3305 g. Four newborn infants (5%) were above the 90th centile for birth weight, and 12% were below the 10th centile. Hypoglycemia was found in 8% of newborn infants. Two infants whose mothers booked for diabetes FIT education only after conception had malformations. The rate of cesarean delivery was 25%. Major pregnancy complications were less frequent than in the historical diabetic pregnancy control group. Diabetes-related neonatal complications were reduced to levels found in the general population. These findings suggest that structured group education that promotes normal and flexible eating may normalize pregnancy outcomes in women with pregestational diabetes.