For pregnant women with preexisting diabetes, tight glycemic control is recommended to reduce the risk of fetal anomalies, macrosomia, delivery complications, stillbirth, and neonatal hypoglycemia. We performed a systematic review to determine the comparative effectiveness and safety of the main options for achieving tight glycemic control during pregnancymultiple daily injections (MDI) of insulin or continuous subcutaneous insulin infusion (CSII).
We searched MEDLINE (1966 to July 2011), EMBASE (1974 to July 2011), and Cochrane Central Register of Controlled Trials (1966 to July 2011) using search terms related to diabetes mellitus and insulin delivery with no language limits. We included randomized controlled trials and observational studies with a concurrent comparison group that evaluated CSII and MDI among pregnant women with diabetes. We excluded studies in which Regular insulin was used in the CSII arm as it is not the current practice. Two authors independently reviewed titles, abstracts, and full text articles for eligible studies. We conducted metaanalyses using the DerSimonian and Laird randomeffects model.
We included 6 observational studies (2 prospective and 4 retrospective) evaluating CSII versus MDI therapy in pregnant women with Type 1 diabetes. There were no studies in those with Type 2 diabetes. All 6 studies reported an improvement in hemoglobin A1c in both groups without any significant difference between groups in any trimester. Metaanalysis of four retrospective studies showed no difference for CSII compared with MDI in the rate of Cesarean section (pooled relative risk [RR], 1.01; 95% confidence interval (CI), 0.861.20) or maternal hypoglycemia (RR, 0.78; 95% CI, 0.232.65). Metaanalysis of three retrospective cohort studies showed a pooled mean betweengroup difference in birth weight of 107.2 g (95% CI, -86.6 to 295.9 g), which was not significant. There was no difference between CSII and MDI for maternal weight gain, gestational age at delivery, neonatal hypoglycemia, occurrence of major congenital anomalies, or admission to a neonatal intensive care unit. The studies had moderate to high risk of bias, with incomplete descriptions of study methodology, study populations, interventions, and outcomes.
Observational studies reported a similar improvement in hemoglobin A1c during pregnancy with CSII and MDI interventions, but the evidence was insufficient to rule out the possibility of important differences between CSII and MDI for maternal and fetal outcomes. Stronger study designs are needed to improve understanding of the comparative effectiveness of CSII and MDI in pregnant women.
To cite this abstract:Bass E, Yeh H, Wilson L, Maruthur N, Ranasinghe P, Golden S, Brown T, Suh Y, Berger Z. Comparative Effectiveness of Continuous Subcutaneous Insulin Infusion with Multiple Daily Injections Among Pregnant Women with Diabetes Mellitus: A Systematic Review. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97617. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/comparative-effectiveness-of-continuous-subcutaneous-insulin-infusion-with-multiple-daily-injections-among-pregnant-women-with-diabetes-mellitus-a-systematic-review/. Accessed July 21, 2019.