**1. Introduction**

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62 Telemedicine

2399-400.

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Diabetes is the most common complication of gestation, and this condition is associated with a higher frequency of maternal and fetal complications. Gestational diabetes mellitus (GDM), defined as glucose intolerance with onset or first recognition in pregnancy that is not clearly overt diabetes (ADA, Standards of Medical Care, 2013), is responsible for the ma‐ jority of these complications and affects 1–14% of all pregnancies, becoming a growing health concern (Albrecht et al, 2010). Although diabetes types 1 and 2 are proportionally smaller contributors to this problem, the prevalence of pregnancies complicated by preges‐ tational diabetes is rising as a result of certain environmental risk factors and the exponen‐ tial increase in obesity (Wendland et al, 2011).

There is a well-documented relationship between a good glycemic control in healthy or dia‐ betic pregnant women and lower rates of congenital malformations and perinatal complica‐ tions (Ballas et al, 2012). On the other hand, despite the increasing number of pregnant women with diabetes, there has been a gradual decline in the amount of attention paid by specialists to the follow-up of these patients, and the dwindling economic resources allocat‐ ed to public health services mean that access to specialized healthcare facilities is becoming more difficult. Attending a metabolic care unit can prove difficult for other reasons too (e.g. for women living too far away, or with no independent means of transportation, or needing

© 2013 Chilelli et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Chilelli et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

to rest to avoid preterm delivery). In this complex and worrying scenario, exploiting new technologies may be a ploy to ensure the effective management of these patients.

**N° of partecipants (intervention/control)**

**2. Goals of telemedicine: pregnancy and fetal outcome**

clinic are important potential modifiers of most of these factors.

duced by treatment (McCance DR, 2011).

nv: not valued

**Clinical outcome (metabolic/QoL)**

**Pérez-Ferre N, 2009** 49/48 =/nv nv ↑ **Pérez-Ferre N, 2010** 49/48 =/↑ ↑ ↑ **Homko CJ, 2007** 32/25 =/↑ ↑ nv **Homko CJ, 2012** 40/40 =/↑ ↑ nv **Dalfrà MG, 2009** 88/115 ↑/↑ ↑ nv

For more details about the "clinical, behavioral and care coordination" outcomes, refer to Verhoeven et al, 2010

**Table 2.** Brief summary of the main outcomes of the studies conducted in pregnants with GDM. QoL: quality of life;

Maternal hyperglycemia prompts the passage of more glucose to the fetus, causing fetal hy‐ perinsulinemia and an overgrowth of insulin-sensitive (especially adipose) tissue, which lead to an unbalanced growth of the fetus and the consequent risk of greater trauma at birth, shoulder dystocia and perinatal death. Hyperinsulinemia can also cause numerous neonatal metabolic complications, such as hypoglycemia, hyperbilirubinemia, hypocalcemia, hypo‐ magnesemia, polycythemia, respiratory distress syndrome, and a higher long-term risk of diabetes mellitus and obesity in the child. Diabetes in pregnancy is related to maternal com‐ plications too, such as hypertension, pre-eclampsia, a greater need for caesarean delivery, and a higher risk of developing diabetes mellitus later on. Pregnancy complicated by obesity is characterized by higher adverse maternal and fetal outcome rates too, especially in GDM patients (Lapolla et al, 2009). Education for women at risk and regular visits to an antenatal

In this setting, the HAPO Study enrolled more than 23,000 women attending 15 antenatal centers all over the world, considerably improving our understanding and demonstrating that even mild degrees of hyperglycemia in pregnancy are associated with increased fetal fatness, cesarean delivery and neonatal hypoglycemia, all against a background of a bio‐ logical increase in fetal insulin production. The HAPO study was supported by two re‐ cent randomized trials (Crowther CA, 2005; Landon MB, 2009) confirming that treatment for mild hyperglycemia (largely by means of changes in lifestyle) is effective in improv‐ ing a number of maternal and fetal outcomes. In both the latter trials, birth weights and the frequency of large for gestational age (LGA) babies and pre-eclampsia were all re‐

The best approach to women with pregnancies complicated by diabetes is therefore inten‐ sive, involving frequent glucose self-monitoring and dietary restrictions and/or adequate in‐

**Behavioural outcome**

Better Ways to Cope with Increasingly Common Diseases: The Impact of…

**Care coordination outcome**

65

http://dx.doi.org/10.5772/57018

Telemedicine, or the use of information and communication technology (ICT) to provide medical care at a distance, is one such opportunity, in its various applications that differ mainly in terms of the mode of interaction, the monitoring method, and the types of device involved (Klonoff DC, 2012).

The basic principle behind telemedicine is to use ICT to facilitate the interaction between health professionals and patients. The current inability to assure certain patients a regular, direct contact with their healthcare providers can be offset by using telemedicine applica‐ tions, teleconsultations and videoconferencing. Using telemedicine to support pregnant women with diabetes could have an impact not only on the classical maternal-fetal out‐ comes, but also on other aspects not always taken into due account in the management of these patients, i.e. their quality of life, their perception of the effectiveness of care ("diabetes self-efficacy"), and their glycemic variability (Mastrogiannis et al, 2013).

Little research has been conducted on the impact of telemedicine systems on clinical out‐ comes in women with pregnancies complicated by diabetes. In this chapter we analyze the currently available evidence regarding the use of telemedicine in this scenario (Table 1 and Table 2), trying to highlight the main limitations of the trials performed to date and possible strategies to overcome them with a view to improving the efficacy of future clinical inter‐ ventions involving these medical applications.


For more details about the "clinical, behavioral and care coordination" outcomes, refer to Verhoeven et al, 2010

**Table 1.** Brief summary of the main outcomes of the studies conducted in pregnants with type 1 diabetes. QoL: quality of life; nv: not valued


For more details about the "clinical, behavioral and care coordination" outcomes, refer to Verhoeven et al, 2010

**Table 2.** Brief summary of the main outcomes of the studies conducted in pregnants with GDM. QoL: quality of life; nv: not valued

## **2. Goals of telemedicine: pregnancy and fetal outcome**

to rest to avoid preterm delivery). In this complex and worrying scenario, exploiting new

Telemedicine, or the use of information and communication technology (ICT) to provide medical care at a distance, is one such opportunity, in its various applications that differ mainly in terms of the mode of interaction, the monitoring method, and the types of device

The basic principle behind telemedicine is to use ICT to facilitate the interaction between health professionals and patients. The current inability to assure certain patients a regular, direct contact with their healthcare providers can be offset by using telemedicine applica‐ tions, teleconsultations and videoconferencing. Using telemedicine to support pregnant women with diabetes could have an impact not only on the classical maternal-fetal out‐ comes, but also on other aspects not always taken into due account in the management of these patients, i.e. their quality of life, their perception of the effectiveness of care ("diabetes

Little research has been conducted on the impact of telemedicine systems on clinical out‐ comes in women with pregnancies complicated by diabetes. In this chapter we analyze the currently available evidence regarding the use of telemedicine in this scenario (Table 1 and Table 2), trying to highlight the main limitations of the trials performed to date and possible strategies to overcome them with a view to improving the efficacy of future clinical inter‐

**Wójcicki JM, 2001** 15/15 ↑/nv nv nv

**Ładyżyński P, 2001** 15/nv ↑/nv ↑ nv

**Ładyżyński P, 2007** 15/15 =/↑ nv nv

**Di Biase N, 1997** 10/10 ↑/nv nv nv

**Frost D, 2000** 11/10 ↑/nv nv nv

**Dalfrà MG, 2009** 17/15 =/↑ ↑ nv

For more details about the "clinical, behavioral and care coordination" outcomes, refer to Verhoeven et al, 2010

**Table 1.** Brief summary of the main outcomes of the studies conducted in pregnants with type 1 diabetes. QoL:

**Clinical outcome (metabolic/QoL)** **Behavioural outcome**

**Care coordination outcome**

technologies may be a ploy to ensure the effective management of these patients.

self-efficacy"), and their glycemic variability (Mastrogiannis et al, 2013).

ventions involving these medical applications.

quality of life; nv: not valued

**N° of partecipants (intervention/control)**

involved (Klonoff DC, 2012).

64 Telemedicine

Maternal hyperglycemia prompts the passage of more glucose to the fetus, causing fetal hy‐ perinsulinemia and an overgrowth of insulin-sensitive (especially adipose) tissue, which lead to an unbalanced growth of the fetus and the consequent risk of greater trauma at birth, shoulder dystocia and perinatal death. Hyperinsulinemia can also cause numerous neonatal metabolic complications, such as hypoglycemia, hyperbilirubinemia, hypocalcemia, hypo‐ magnesemia, polycythemia, respiratory distress syndrome, and a higher long-term risk of diabetes mellitus and obesity in the child. Diabetes in pregnancy is related to maternal com‐ plications too, such as hypertension, pre-eclampsia, a greater need for caesarean delivery, and a higher risk of developing diabetes mellitus later on. Pregnancy complicated by obesity is characterized by higher adverse maternal and fetal outcome rates too, especially in GDM patients (Lapolla et al, 2009). Education for women at risk and regular visits to an antenatal clinic are important potential modifiers of most of these factors.

In this setting, the HAPO Study enrolled more than 23,000 women attending 15 antenatal centers all over the world, considerably improving our understanding and demonstrating that even mild degrees of hyperglycemia in pregnancy are associated with increased fetal fatness, cesarean delivery and neonatal hypoglycemia, all against a background of a bio‐ logical increase in fetal insulin production. The HAPO study was supported by two re‐ cent randomized trials (Crowther CA, 2005; Landon MB, 2009) confirming that treatment for mild hyperglycemia (largely by means of changes in lifestyle) is effective in improv‐ ing a number of maternal and fetal outcomes. In both the latter trials, birth weights and the frequency of large for gestational age (LGA) babies and pre-eclampsia were all re‐ duced by treatment (McCance DR, 2011).

The best approach to women with pregnancies complicated by diabetes is therefore inten‐ sive, involving frequent glucose self-monitoring and dietary restrictions and/or adequate in‐ sulin therapy (Landon MB, 2011). Using telemedicine can facilitate the management of pregnancy complicated by diabetes, being applicable to all the above-mentioned areas of in‐ tervention. The great challenge now is to demonstrate the efficacy of this innovative tool in terms of maternal-fetal outcome and an advantageous cost/benefit ratio.

(ΔMBG = -3.2 +/- 4.3 mg/dL, p = 0.0016, ΔJ = -1.4 +/- 2.3, p = 0.0065). They also found a ten‐ dency for a better glycemic control in patients with a lower intelligence quotient (IQ < 100) supported by the telematic system by comparison with all the other groups of patients, though this difference lacked statistical significance. The telematic intensive care system im‐

Better Ways to Cope with Increasingly Common Diseases: The Impact of…

http://dx.doi.org/10.5772/57018

67

Ladyzynsky et al developed a system for supporting intensive insulin treatment in pregnant women with type 1 diabetes. The system consists of a patient teletransmission module (PTM) and a central clinical control unit (CCU). The PTM comprises a box containing a blood glucose meter and an electronic logbook, a modem for dial-up internet or a cellular phone set. The CCU consists of a PC with a modem and DIAPRET software – a dedicated program designed to monitor the intensive insulin treatment. The system was tested on 15 pregnant type 1 diabetic women for 166±24 days. Its total effectiveness was 69.3±13.0% and its technical effectiveness was 91.5±6.1%, and was not significantly influenced by the pa‐ tients' IQ, formal education or place of residence, while it turned into a better metabolic con‐

The same authors also assessed the influence of the greater frequency of data reporting on diabetic patients' metabolic control. Data were reported via a home telecare system that stored blood glucose levels and was integrated with a simple electronic logbook. The data collected by patients were automatically transmitted via the telephone network every night. The study population consisted of 30 patients with type 1 diabetes, who were randomly al‐ located to the home telecare group or a control group. The control group's treatment was based on clinical examinations performed every three weeks. For the home telecare group, the data recorded by patients were transmitted to the hospital daily, enabling doctors to in‐ tervene more frequently. The average duration of the study was 180 days (standard devia‐ tion, SD 22) in the home telecare group and 176 days (SD 16) in the control group. The mean level of metabolic control and the insulin dose adjustment patterns were very similar in the two groups despite the much greater (15-fold) reporting frequency in the home telecare group. The data collected by patients were not fully usable, mainly because of an excessively high within-day variability in glycemic control and the high workload for the hospital staff performing the daily data analysis. On average, for the home telecare group, the patients' data were collected about 0.7 times per day (i.e. 15 times more often than in the case of rou‐ tine treatment), although average metabolic control was found only slightly better for the home telecare group than for controls, and the number of adjustments to patients' insulin doses was very similar in the two groups. Both general compliance issues (relating to the considerable effort needed to analyze the daily data) and clinical problems (e.g. a high intraday glycemic variability) probably contributed to the lack of any significant differences be‐ tween the two groups. These findings prompted the authors to conclude that remote systems used at home by patients with type 1 diabetes on intensive insulin therapy im‐ proves their glycemic control, but needs to support real-time data transmission and be com‐ bined with appropriate data analysis and subsequent decision-making for it to achieve any

real improvement in the quality of care (Ładyżyński et al, 2007).

proved the efficacy of diabetes treatment during pregnancy (Wójcicki JM, 2001).

trol (Ładyżyński et al, 2001).
