Commentary by Kristen Nadeau, MD, MS
“The major take away, is that adolescents and young adult women with type 2 diabetes are at high risk for pregnancy, likely due to low socioeconomic status-related factors, yet current approaches to preconception counseling are not effective in preventing unplanned pregnancy,” said study coauthor Kristen Nadeau, MD, MS, Associate Professor of Pediatric Endocrinology, University of Colorado Denver/Childrens Hospital Colorado, Aurora.
The subjects (N=452; ages 10-17 years) were told that contraception or abstinence was necessary for participation in the study during the informed consent process and this requirement was reinforced at each visit. Despite this requirement, 46 participants (10.2%) had 63 pregnancies during an average follow-up of 3.8 years.
Only 3 subjects who became pregnant (4.8%) reported using contraception prior to conception, and only 8 participants (13.3%) remembered having received diabetes-specific counseling on the importance of using adequate contraception during the study.
High Rate of Pregnancy Loss and Congenital Anomalies Found
Pregnancy loss occurred in 14 of the 53 pregnancies (26.4%) that were not electively terminated and for which data were available. Congenital anomalies were found in 8 of the 39 live births (20.5%). These anomalies included cardiac anomalies in 4 infants and polycystic kidney disease, microcephaly, cleft palate, and jejunal atresia in 1 infant each.
“The rates of congenital anomalies in adolescents with type 2 diabetes were 4 times higher than expected based on pregnancies in adult women with diabetes,” Dr. Nadeau said. “These concerning pregnancy outcomes, coupled with the rising rates of type 2 diabetes in adolescents globally are very worrisome.”
“While we suspect factors such as hyperglycemia, hyperlipidemia, and obesity [are causative], our data did not point to obvious causes of the high rates of congenital anomalies,” Dr. Nadeau said. “Therefore we need research to better understand the reasons for the high rates of congenital anomalies in these young women, in order to know what factors during pregnancy to target.”
Participants who became pregnancy were older at the time of randomization (15 vs 13 years of age; P<0.0001) and were more likely to be living outside of their parent’s home (P=0.008) and have a lower household income (P=0.03).
Tips for Counseling Teens With Diabetes About Pregnancy
“Girls with type 2 diabetes need to be reminded continuously to avoid pregnancy until their glycemic control is improved, and to contact their diabetes provider as soon as possible if they do become pregnant,” Dr. Nadeau said. “However, since adolescents are the most difficult population to achieve glycemic control in, we also need to routinely encourage long-acting contraception in those who may be at highest risk for an unexpected pregnancy, ie, those who may not plan NOT to get pregnant. Long-acting contraception is ideal for high-risk adolescents as it does not require compliance with daily medication and protects against the unplanned sexual encounters characteristic of teens.”
“This is an important topic since type 2 diabetes in youth is relatively new and this is the first information on pregnancy outcomes in these adolescents and young women,” Dr. Nadeau concluded. “We need research into better ways to deliver preconception counseling that is developmentally and culturally appropriate for the adolescent type 2 diabetes population, so that unplanned pregnancy, especially in the setting of poor diabetes control, can be avoided.”
New ADA Recommendations on Diabetes Management in Pregnancy
The TODAY study findings coincide with the release of the American Diabetes Association’s (ADA's) 2016 Standards of Medical Care in Diabetes, which offers new recommendations on pregestational diabetes, gestational diabetes, and diabetes management in pregnancy.
The ADA recommends a preconception hemoglobin A1C of <6.5%, to reduce the risk of congenital anomalies and that effective contraception should be prescribed until an woman is prepared to become pregnancy.
During pregnancy, the ADA recommends an A1C target of 6–6.5% and notes that <6% may be optimal if this target can be achieved without significant hypoglycemia. In addition, the target may be relaxed to <7% if necessary to prevent hypoglycemia.
January 8, 2016
Klingensmith GJ, Pyle L, Nadeau KJ, et al. Pregnancy outcomes in youth with type 2 diabetes: the TODAY study experience. Diabetes Care. 2015 Dec 1. pii: dc151206. [Epub ahead of print]
American Diabetes Association. Standards of Medical Care in Diabetes-2016: 12. Management of Diabetes in Pregnancy. Diabetes Care. 2016;39(Suppl 1):S94–S98.