Managing T1D During Pregnancy With Closed-Loop Insulin Delivery: Camilla Levister

Camilla Levister, MS, ANP-C, CDCES, a nurse practitioner at the Icahn School of Medicine at Mount Sinai Hospital in New York, discusses the risks associated with hypoglycemia and hyperglycemia in pregnant patients with type 1 diabetes (T1D), as well as how a closed-loop insulin delivery system, or artificial pancreas, can help reduce the burden of T1D management during pregnancy.

Levister and colleagues at Mount Sinai have collaborated with other institutions to customize an artificial pancreas system for pregnant patients with T1D, who have tighter glucose targets compared with people with T1D who are not pregnant. Clinical trials were conducted by a consortium including Mount Sinai; Mayo Clinic in Rochester, Minnesota; and the Sansum Diabetes Research Institute in Santa Barbara, California.

Transcript

What are the risks associated with managing type 1 diabetes in pregnancy, and how are these addressed in a closed-loop system?

Because the glucose targets during pregnancy are tighter and on the lower side compared to those outside of pregnancy, there is a risk for hypoglycemia, or low blood sugar, when you have a system that's being more aggressive in terms of managing glucose and keeping it on the lower side as opposed to higher. One of the concerns that you have—not just with a closed-loop system, but when a woman is managing diabetes, either with injections or a insulin pump that is not part of a closed-loop system, or artificial pancreas system—is you have concern for severe low blood sugars that can lead to loss of consciousness or seizure. This was also a concern that we had for our participants in the study.

One of the things about a closed-loop system is that it can decrease, or stop, insulin delivery when the glucose was predicted to go below a certain level, and that will help with preventing hypoglycemia. This can still occur, but we did see a reduction in hypoglycemia in those that use the system compared to prior when they were not using the system.

A few of the concerns in regards to hyperglycemia during pregnancy are preeclampsia for the mother, medically indicated preterm delivery for the unborn child. You have risk for the child being born large for gestational age, which increases the need for cesarean section. And for those that are vaginally delivered, you have a higher risk for something called shoulder dystocia, where the shoulder can get caught in the birth canal during delivery and cause trauma to the child. You also have concerns for things like fetal death for placental malfunction and for delayed lung maturity. Those are all concerns that we have. That's one of the things that's driving us to help these patients to have an increased percent of time within target range to help prevent those complications from occurring.

And of course, the other thing that we want to do is, we want to help to relieve the patient's burden. You're always going to be thinking about glucoses and the safety of your baby during pregnancy with type 1 diabetes—I think that's something that we can't get rid of. But if a patient has the sense that they have a system that they're working with that can prevent them from having severe low blood sugars, potentially that can reduce their risk of having really high blood sugars, maybe it allows them to have a little less burden in regard to the both emotional impact and then just the day-to-day impact in regard to management. Maybe it allows them to partake in activities that they wouldn't usually partake in because they'd have concerns about it—and also just get a better night's sleep because they don't have as many concerns about running really high overnight or running really low overnight.

Reference

Levy CJ, Kudva YC, Ozaslan B, et al. At-home use of a pregnancy-specific zone-MPC closed-loop system for pregnancies complicated by type 1 diabetes: a single-arm, observational multicenter study. Diabetes Care. 2023;46(7):1425-1431. doi:10.2337/dc23-0173