title: Falling insulin requirements are associated with adverse obstetric outcomes in women with preexisting diabetes.
abstract: OBJECTIVE
  To investigate the clinical significance of falling insulin requirements in women with preexisting or overt diabetes in pregnancy.
  
  
  METHODS
  A retrospective review of 139 pregnancies was conducted in women, with preexisting diabetes, delivering between January 2010 and January 2013. Women with falling insulin requirements of 15% or more from the peak total daily dose in late pregnancy were considered case subjects (n = 35). The primary outcome consisted of a composite of clinical markers of placental dysfunction, including preeclampsia, small for gestational age (SGA, ≤5th percentile for gestational age), stillbirth (>20 weeks), and premature delivery (≤30 weeks).
  
  
  RESULTS
  A total of 25.2% of women had >15% fall in insulin requirements with nulliparity as the only predictor at baseline (odds ratio [OR] 2.5 [95% CI 1.1-5.7], P = 0.03). Falling insulin requirements were associated with an increased risk of preeclampsia (OR 3.5 [1.1-10.7], P < 0.05) and the composite of clinical markers of placental dysfunction (4.4 [1.73-11.26], P = 0.002). Although falling insulin requirements were associated with higher rates of SGA (3.4 [1.0-11.3], P = 0.048), they were not associated with other adverse neonatal outcomes. However, there was a higher incidence of neonatal intensive care unit admission (15.5 [3.1-77.6], P = 0.001) and earlier delivery in this group (median 37.7 weeks [IQR 34.3-38.4] vs. 38.3 weeks [37.4-38.9], P = 0.014).
  
  
  CONCLUSIONS
  Falling insulin requirements, in women with preexisting diabetes, are associated with an increased risk of complications related to placental dysfunction. Further prospective studies are needed to guide clinical management.
authors: Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia School of Medicine, University of Sydney, Sydney, New South Wales, Australia suja_padman@yahoo.com.au.
authors: Suja
authors: S
authors: Padmanabhan
authors: Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia Department of Diabetes and Endocrinology, Blacktown Hospital, Blacktown, New South Wales, Australia School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia.
authors: Mark
authors: M
authors: McLean
authors: Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia School of Medicine, University of Sydney, Sydney, New South Wales, Australia.
authors: N Wah
authors: NW
authors: Cheung
mesh_terms: D000328:Adult; D003920:Diabetes Mellitus / Q000188:drug therapy* / Q000503:physiopathology; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D015994:Incidence; D007230:Infant, Low Birth Weight / Q000502:physiology; D007328:Insulin / Q000627:therapeutic use*; D010298:Parity; D010920:Placenta / Q000503:physiopathology*; D011225:Pre-Eclampsia / Q000453:epidemiology / Q000503:physiopathology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000188:drug therapy* / Q000503:physiopathology; D011256:Pregnancy Outcome; D011263:Pregnancy Trimester, Third / Q000502:physiology; D047928:Premature Birth / Q000453:epidemiology*; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D050497:Stillbirth / Q000453:epidemiology*
chemical_list: D007328:Insulin