Automated Insulin Delivery in Pregnancies Complicated by Type 1 Diabetes

Abstract

Automated insulin delivery (AID) systems adapt insulin delivery via a predictive algorithm integrated with continuous glucose monitoring and an insulin pump. Automated insulin delivery has become standard of care for glycemic management of people with type 1 diabetes (T1D) outside pregnancy, leading to improvements in time in range, with lower risk for hypoglycemia and improved treatment satisfaction. The use of AID facilitates optimal preconception care, thus more women of reproductive age are becoming pregnant while using AID. The effectiveness and safety in pregnant populations of using AID systems with algorithms for non-pregnant populations may be impacted by requirements for lower glucose targets and existence of increased insulin resistance during gestation. The CamAPS FX is the only AID system approved for use in pregnancy. A large randomized controlled trial (RCT) with this AID system demonstrated a 10.5% increase in time in pregnancy range (an additional 2.5 hours/day) compared with standard insulin therapy in pregnant women with T1D with a baseline glycated hemoglobin A1c (HbA_1c) ≥48 mmol/mol (6.5%). A RCT of AID not approved for use in pregnancy (MiniMed 780G) has also demonstrated some benefits of AID compared with standard insulin therapy with improved time in pregnancy range overnight (24 minutes), less hypoglycemia, and improved treatment satisfaction. There is also increasing evidence that AID can be safely continued during delivery and postpartum, while maintaining glycemic goals with lower risk for hypoglycemia. More AID systems are needed with flexible glucose targets in the pregnancy range and possibly with algorithms that better adapt to changing insulin requirements. More evidence is needed on the impact of AID on maternal and neonatal outcomes. We review the current evidence on the use of AID in pregnancy and postpartum.