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Dr. Chapa (7:53)

and participate in McDonald's while supplies last. This is Dr. Chapma's ob gyn. No spin podcast. Foreign. Tasting the pee pee of patients. Not in my job description. Yep, it was 1674 when English doctor Thomas Willis first described diabetic urine as having a quote. Guys, I'm quoting this from the text. I'm looking at it right here, okay? The history of medicine quote. Wonderfully sweet, as if it had been imbued with honey or sugar. Nasty, nasty man. 1674. Hence the water tasters. Aw, that's so sweet. Now, now that we've covered that nonsense back on track. All right, so first, to be clear, yes, there's the best data for CGMs. And guys, remember, that's continuous glucose monitors for patients with Pre existing type 1 diabetes. So class B or further down the letters in pregnancy. Then the second big box is for type 2 diabetes. We're going to talk about time and range and all that business in a minute. But to be very clear, yes, best data is for those, and the best are when CGMs are combined with flash glucose reads. In other words, you tell them two hours after you eat, you put the phone or the app next to the sensor or whatever the device is, and you get yourself a spot glucose. Okay? Because that's gonna mimic the best finger sticks. All right, so while continuous glucose reads is kind of automated and it picks times during the day where it picks a read of the interstitial fluid, you can also do a flash assessment, and you should do that again, fasting, and then two hours postprandule to include that in into the final read. Okay? So the best is to do flash monitors with continuous feature as well. And now all these apps are super smart. You can actually change the bump. You know, the time and range of boundaries that you want. I know you can do that with Dexcom, the new sensor. Again, not a sponsor. So now that we've talked about all that, let's talk about this issue of tir, because we got to get our mind around that. It's not just fasting under 95 or 2 hours, postprandial under 120. We have to understand TIR, the time and range, which is based on the majority of the day, like 70% or greater if you're type 1 diabetic or greater than 90% time and range of your adult onset or GDM, that's the amount of time that you need to fit in the green zone. Okay? Now, the reason it's greater as time and range for type 2 or gestational diabetics is because they have the ability to get under better control, whereas type 1 might not be able to do that because of the endocrinology pathology that they have. All right, so type 1, it's allowed to kind of be a little bit more forgiving with 70% time and range and no more than 25% percent above range and less than 5% under range. Right. So hypoglycemic. But for type 2 and gestational diabetics, which is what we're talking about here. The time and range is set as high as 90% as a goal. Some are a little bit more forgiving and go to 85% with a time above range, a tar, dropping that down to about 5 or 15% based on who you read. All right, so the goal is time in range and it is greater than 90% desired for these patients with type 2 diabetes or GDM. So yes, I get that the majority of the data is for type one. Then the biggest chunk of data comes for type two. But here's what we're talking about, guys, this evolving new kid on the block where sensors are being used more and more frequently for gdm. Now, to be clear again, I don't want to get any ugly messages because I get them enough, thank you very much. That the standard, the gold standard, the tradition is still fingerstick and then two hours postprandial or one hour postprandial if that's your mojo. And if it's one hour, you're looking for a sugar under 140 capillary or under 120 at two hours. Okay, but asking a patient to get four sticks a day, as we mentioned in the intro, is a lot to ask. These things do work and we do have evolving data. So that's what I wanted to do. I wanted to start, we're going to start in 2022. We're going to do this in rapid fire succession, ending with 2026, our present day. All right, so let's just quickly do this. I'm going to give you some names and some references here. Amy Valent is one very, very, very cool lady. Super smart and diabetes is her mojo. And we've covered again her work in the past, mainly insulin initiation for type 1 diabetes. We've covered her regimens on the show in the past. So very quickly, let's start with 2022. Remember, it's not just about technology. It's not just about having a test or a new device. It's we want those to improve outcomes. We need outcome driven data, which is one of the gaps. For example, with like the, the new test for prediction of preeclampsia that we talked about in Compass. Great technology, how does it change outcomes? We need it to change outcomes. And that was the question here, do CGMs in GDM change outcomes? The answer that's evolving is yeah, it seems to. Even though there's some limitations and questions that still remain. Okay, I want to be very clear. I'LL talk about that at the end. There are still gaps in the knowledge that we, but we're going to figure that out and that's going to come very, very quickly because this is moving fast. All right, so let's start in 2022 with a meta analysis. So in 2022 there was already data in a population pool to draw from to make a, a meta analysis. And this was of 6 RCTs. It was an end of 482 women. Short of it is does continuous glucose monitor use in gestational diabetes? That's our, our focus here. Gdm. Is that associated with some kind of improvements in mainly in terms of infant birth weight and in objective markers like hemoglobin A1C. Does that change? The answer was yes. CGM use in gestational diabetes was associated with lower hemoglobin A1Cs at the end of pregnancy, less gestational weight gain and lower infant birth weights. Now I get it. You're saying where's the morbidity there? We're talking about a birth weight. Is this change morbidity? Hold on, hold on. We just started the game, homie. We just started this game. So this was 2022 meta analysis. It improves infant birth weight, it Improves Hemoglobin A1C. That was published in Diabetes Medicine in January of 2022. The title was Efficacy of Continuous Glucose monitoring on maternal and Neonatal Outcomes in GDM A Systematic Review and Meta Analysis. Great, so that takes care of that. Now let's move closer to present time. I told you we're going to do this rapid fire leave 2022 and go to last year, November of 2025. November 2025 as point of reference. We're doing this at the start of April 2026. So this is literally just like five or six months ago, not long ago. Okay, so this was, was a study called the steady sugar trial. You can look up the steady sugar trial, of course. I'll put these references in our show notes as we always do. The journal was Diabetes Diabetes, the journal Diabetes. Women with GDM were enrolled and 120 completed the trial after a 2 to 1 randomization to the intervention which was the Dexcom, not a sponsor, Dexcom G6 or a control which was self monitored blood sugars for four times a day. Now those who had self monitored blood sugars also had blinded CGM wearing. In other words, they wore the device. They didn't know the results. That went to the investigators. All right, so just the monitor or finger sticks with the monitor, but they were blinded to that. The results CGMs did work. CGM Group had significantly lower unscheduled C section rates. That's good. They had lower preterm deliveries and neonates had lower rates of being LGA as well as lower rates of NICU admissions. So this is reassuring. This is called the Steady Sugar Trial. Catch you right. Steady Sugar Trial Continuous glucose monitors from November of 2025. Now I get it if you're saying wait a minute, give me hardcore things. Hold on, we're going to continue here in just a minute. So so far we've got 2022, November 2025 with the steady Sugar trial.

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Dr. Chapa (17:50)

That brings us to a separate RCT by Amy Valent. In 2025 this was published in Diabetes Care. The title was Real Time Continuous Glucose Monitoring in Pregnancies with Gestational Diabetes. A randomized controlled trial. Pretty self explanatory. Well, here's what she found. Quote in patients with gestational diabetes who wear real time continuous glucose monitoring, they were able to achieve significantly higher time in range. That's the desired end spots. I'm gonna tell you what those are in a minute. Compared to capillary blood sugar monitoring alone, the continuous glucose monitoring group also had significantly higher daytime time and range and lower 24 and daytime mean glucose values. In other words, they seem to be under better control. So if you're saying, well, what's the outcome there? It's better glycemic control. So it's not just outcomes for the child, but they got better control because they were able to get direct feedback from this and able to adjust either in lifestyle modification or in some cases with medication therapy. So again, it's about having a variety of different outcomes. Hopefully these horses are better with continuous glucose monitors for GDM, CGM for GDM. So that brings us to 2025. Again, we're still hanging out in this year to a separate systematic review and meta analysis. We already covered a systematic review and meta analysis from 2022, but here is a different one. This also found that continuous glucose monitors in GDM again Significantly reduced hemoglobin A1C and reduced large for gestational age births. This was 5 RCTs. And this was the Burk B U R K et al review from the Gray Journal just from the fall of 2025. This was September of 2025. Now, before we get to 2026, we've got one last one from 2025. This was a secondary analysis from another separate trial called the digest trial. That is DI G S T the digest trial that looked at CGMs for GDM patients. Well, they found that in those patients who maintained greater than 90% time and range. And so that goal is, you know, no lower than like, you know, 69 or so and the top value of 140 traditionally. But they said, you know what, the lower that you go in that control, in that range, ideally under 110 as a mean glucose value, they tended to have the best birth weights and the lowest chance of large for gestational age. And also on the flip side, they had the lowest rates of small for gestational age. So in other words, it improved birth weight outcomes. This was in diabetes Care from August of 2025. Right. Secondary analysis of the Digest trial. Looking at again at birth weights, they found the better time in range at 90% or more with a top bumper not of 140, but you can bring that down to 120 or ideally with a mean gluten value of less than 110. That seemed to be the sweet spot. Now we're almost done here because we're already in 2026. As our next discussion very quickly, this was the Grace trial. G R A C E. The Grace trial. This was published in Lancet Diabetic Endocrinology at the start of the year January 2026. I like this because again, the easiest thing to track for diabetes is how big those babies get. Well, this was an open label RCT. It had an N of 170 women with GDM which looked at, once again, you guessed it, birth weights, and found that CGM did significantly improve the baby's birth weight when they had tight time and range management. So that was the Grace trial. And then one of the last things that we're going to cover is another publication from Amy Valent. Sorry, another data set from Amy Valent. This was discussed at SMFM's annual clinical meeting, February 2026. Yeah, once again this worked. And they included other kinds of secondary outcomes like nicu, respiratory distress, birth injury, usually as a sign of dystocia or hyperbilirubinemia that required phototherapy. As you would think, more time in range with a high cutoff being again, under 120, that was significantly associated with less NICU admissions, less respiratory issues and less severe birth traumatic events. So it seems to do something here for gdm. That was Amy Valent's presentation out of SMFM in February of 2026. However, and guys, we're almost at the end here. However, just to be fair, I have to give you the whole set of data here. Not everybody agrees. Okay, so there was a publication also two months ago in February 2026 that showed not, not a lot of fanfare here for CGMs in GDM. This was a large RCT and is called the Dip Glumo trial. Yeah, Dip Glumo all one set. Dip Glu M O, Dip gloomo trial. This was out of Lancet Diabetes Endocrinology. And what they found was, quote, well, individuals who use this had no real change in significant outcome between those who were a control. However, here it is, guys. Quote, individuals expressed a higher preference for the real time continuous glucose monitor. And so, quote, this finding suggests that these monitors could be offered to simplify the management of gestational diabetes. End quote. You think? I mean, did we need an RCT to figure out, hey, patients would rather pick themselves in the arm once for 10 to 14 days versus four times a day. So yeah, it had better patient satisfaction which led to better compliance. Even though, just to be clear, even though there was no significant improvement or maternal complication decrease in the CGMs compared to standard care. Okay, so that is a bummer. Not everybody agrees. That was February of 2026. The Dipglumo trial, which was a single center RCT, found no big difference compared to standard care. So I'm just trying to give you both sides of the fence, even though you can tell I am a believer. I think CGMs work here. I just. It's unfortunate my patients can't afford it. So mine are usually public assistance and not yet really universally covered, which is a big gap. Now, just to be clear, as we get ready to wrap this up, there are things that we don't know. We don't really know what the true bumpers are for GDM. Traditionally, it's set at 140 as a high end and then like 69 or 64 as the low end to prevent hypoglycemia, but we don't really know if that's the same for GDM or not. That is a gap. And that was just stated in the 2026 international consensus guidance on CGM use in pregnancy. That just came out as well, that we still have more work to do. However, guys, this is evolving quickly. Is there data right now, even in its data infancy, that CGMs can improve some outcomes with GDM management? The answer is yes, no question. Thank you, Amy Valent, for leading the charge of this with your buddies in the Pacific Northwest. Keep it up and there, guys, I can tell you there are clinical trials right now, right now, recruiting patients to look at other outcomes as well. But just from 2022 to 2026, this thing is moving very quickly. So CGMs in pregnancy, absolutely. It is a new arrival. It's the new fancy thing and it can improve patient care and compliance and satisfaction so we don't have to treat them like pin cushions with finger sticks four times a day. However, even though gaps remain in the data for gdm, we can't ignore the value of continuous glucose monitors here. Podcast family as I thought this was interesting because we've had these recent developments. From February 2026, I had somebody who messaged me through our social media channels asking about CGMs for pregnancy and or for GDM. And I'm like, hey, even though we have some gaps, I am a believer in this, so I hope this helps. Now that we've done all that. Michael, let's call it a day. Let's take it home. This is Dr. Chapa's obgyn no spin podcast.