It is over 200 years since the first reports of pregnancy in women with diabetes. Pregnancy outcomes were poor with about half of the mothers and half of the babies dying. The pregnancies were in women with known diabetes, likely type 1, and also newly recognised diabetes based on glycosuria. The introduction of insulin significantly reduced maternal mortality but only modestly improved perinatal mortality and morbidity. Advances in obstetric and neonatal care led to much greater reduction in adverse fetal outcomes.
Over the last 40-50 years there have been changes in the types of diabetes seen in pregnancy: from mainly type 1 diabetes to about 90% having gestational diabetes and increasing rates of type 2 diabetes and of the confounding challenge of obesity. As well there has been greater recognition of other forms of diabetes including the various forms of MODY, and an increase in women with cystic fibrosis or transplants having pregnancies. Diabetes management needs appropriately tailoring for the type of diabetes and to meet the individual’s needs.
Glucose monitoring options have steadily changed from urine testing to visual glucose checking to increasingly accurate glucose meters and now continuous glucose monitoring (CGM). Although CGM has been shown to improve pregnancy outcomes in the type 1 diabetes setting its benefits in other settings are less clear. Glucose targets have been increasingly tightened to improve outcomes.
Medication options have changed with modified insulin preparations and advances in insulin delivery systems. Non-insulin medications remain limited due to safety concerns with even metformin continuing to have a cloud over its longterm safety for the offspring.
All people with diabetes in pregnancy require appropriate education, dietary advice and support with frequent contact and guidance from diabetes health professionals.
Much more progress is still needed in diabetes-specific pregnancy planning and safe use of reliable contraception.