Gestational diabetes

It’s not all about glucose in women with diabetes in pregnancy

Dr Helen Barrett

Should we be considering and even treating disorders of lipid metabolism along with glucose metabolism in women with diabetes in pregnancy?

That was the question posed at the Australasian Diabetes Congress 2018 (ADC 2018) in Adelaide on 24 August by endocrinologist and obstetric medicine physician Dr Helen Barrett.

Dr Barrett, director of endocrinology at Mater Hospital Brisbane, and a senior research fellow at Mater Research, told the limbic women with diabetes in pregnancy and their babies should have the same health outcomes as everyone else.

“And in the last couple of decades we have come a very long way but we are still not quite there. At the moment, when we think about how to manage women, we think very much about their glucose and to some extent about weight gain but we also know that some other aspects of metabolism are altered in the setting of diabetes in pregnancy .”

She said lipids and triglycerides were particularly important but also ketones and amino acids.

“Lipids are not usually tested during pregnancy because we know they change. Even in women without diabetes, they change during pregnancy – triglycerides are higher and the lipoproteins themselves are different.”

“Women with diabetes in pregnancy have an exaggerated version of that and usual medications to treat cholesterol and triglycerides are not medications that we would routinely use in pregnancy.”

Dr Barrett said there was evidence that elevated maternal triglycerides are associated with increased rates of pre-eclampisa, preterm delivery and macrosomia.

But at the moment, there was very little evidence about what to do about it.

Dr Barrett said she was currently exploring how triglycerides change during the day in pregnant women.

“We know with glucose, the way the glucose changes is important. It’s not just the average levels; it’s the peak and troughs that seem to influence foetal growth.”

“It might be that the variation in triglycerides is also important. So far, we’ve shown they do change quite a lot during the day but we’re still working on getting enough information on the relationship with foetal growth.”

She said more also needs to be known about how the placenta processes lipids.

“There is evidence that high triglycerides are associated with maternity outcomes but I think we now need to sit down and start teasing out what precisely that is and some of the underlying metabolism and whether or not we need to treat it.”

“Obviously diet is going to be central. And there are some studies starting to look at the different supplements but they need more research. And then if you decide it is incredibly important then you start looking at medications and testing them.”

She said tight glucose control during pregnancy remained of critical importance.

“But as a group perhaps we need to think more about what else we can look at. Can we add something in? In diabetes outside of pregnancy, we know that different aspects of metabolism affect insulin and we treat all of them.”

“The same as in diabetes outside pregnancy, we need to attack weight, blood pressure, lipids and glucose. Within pregnancy we look at glucose. And that’s because we know treating glucose is safe and proven. That doesn’t mean we shouldn’t be exploring the other options.”

Dr Barrett said larger cohort studies would be essential to tease out subtle metabolic interactions between lipid and glucose metabolism.

Studies in women with familial lipid disorders might also provide useful insight.

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