This is the second pregnancy of a 30-year-old woman with type 1 diabetes since the age of 6. She had non-proliferative diabetic retinopathy since 2011. In the 2018, the patient had tried continuous subcutaneous insulin infusion (CSII) therapy which was discontinued due to discomfort. The first pregnancy was in 2019 and resulted in a dystocic birth at 37 weeks gestation due to altered cardiotocographic tracing, a 3975 g male. During the first pregnancy, the patient was on controlled therapy with MDI and intermittently scanned continuous glucose monitoring (isCGM), and the pregnancy described in this report was unplanned. Prior to conception, she had an A1C of 6.7% and a pre-pregnancy weight of 70 kg (BMI 23.4 kg/m²). She was treated with MDI: insulin aspart with an ins/cho ratio (ICR) of 1/8 at breakfast, 1/7.5 at lunch and 1/10 at dinner before each meal plus insulin glargine at a dose of 9 units nightly at bedtime. She was still monitoring her glucose levels with both SMBG and isCGM. In the month prior to conception, her overall mean sensor glucose was 134 mg/dL with a coefficient of variation (CV) of 41%, indicating unhealthy glycaemic control. The patient was referred to our Centre at 13 weeks' gestation. In the first trimester of pregnancy her isCGM readings were: ps-TIR 68% of the time, ps-TBR <63 mg/dL 6% of the time and <54 mg/dL 2% of the time and ps-TAR 24% of the time. At 15 weeks' gestation, therapy was switched from MDI and isCGM to the InPen ^TM integrated with the Guardian 4 CGM system. Pregnancy-specified target and duration of insulin action (IOB) were set up (2.5 hours). The ICR and the insulin sensitivity factors used to calculate dose recommendations were also specified in the system. PS-TIR increases to 74% in the first 2 weeks of InPen ^TM use. She noticed an increase in her insulin requirements, with postprandial hyperglycaemia (both morning and afternoon), and the ICR was reduced to 6.5 g in the morning and 5.5 g in the afternoon for more bolus insulin. At 27 weeks' gestation she achieved ps-TIR over 89%, ps-TAR 7%, ps-TBR 4% and GMI 5.9 % without severe hypoglycemia. Time above range of 19% noted during the second trimester was decreased to 7% in the third trimester. The total daily insulin dose was adjusted during the pregnancy. Good control with time below range <5% was maintained in the third trimester (Figure 1). At the end of pregnancy her gestational weight gain was 14 Kg. The patient gave birth to a male infant at 38 weeks' gestation with a weight of 3980 g and a length of 53 cm (Apgar at 1’ e 5’, 9 and 10 respectively). His size was large for gestational age (LGA) with no congenital malformations; the infant required temporary monitoring for hyperbilirubinemia 3 days after birth which resolved with phototherapy. At 4 weeks postpartum, the infant was healthy and the mother had maintained stable glycaemic control (mean glucose level 115 ± 49 mg/dl, CV 43.0%, GMI 6.1%).

A 36-year-old woman, presented at 8 weeks' gestation in January 2024. She had type 1 diabetes since 2003 and Hashimoto's thyroiditis since 2010. She was treated with MDI and an intermittently scanned glucose meter (isCGM). She did not plan the pregnancy, she was on MDI: insulin aspart 2 units at breakfast, 3 units at lunch and 4 units at dinner and insulin glargine U300 10 units at bedtime. She has no knowledge of CHO counting. Her pre-pregnancy weight was 60 kg, her pre-pregnancy BMI was 21.5 kg/m2, and her HbA1c a month prior to conception was 6.8%. In the first trimester of pregnancy her isCGM readings were: ps-TIR 64% of the time, ps-TBR <63 mg/dL 10% of the time and <54 mg/dL 4% of the time and ps-TAR 22% of the time. At 10 weeks' gestation, therapy was upgraded with InPen ^TM integrated with the Guardian 4 CGM system. Pregnancy-specified target and duration of insulin action (IOB) were set up (2.5 hours). She was not able to apply CHO counting method so the dose calculator of the system mobile app was set with fixed doses. Dose calculator of InPen ^TM system helped patient in adjusting insulin doses at meals and correct hyperglycaemia, avoiding hypoglycaemia due to excessive correction boluses. At 28 weeks' gestation she achieved ps-TIR over 84%, ps-TAR 12%, ps-TBR 4% and GMI 5.6% with a reduction in hypoglycemic events. The total daily insulin dose was adjusted during the pregnancy. At 37 weeks’ her HbA1c was 5.4% ps-TIR 90%, ps-TAR 6% and ps-TBR 2 + 2% with a overall mean sensor glucose 97 mg/dl and CV 24.5% (Figure 2). The total daily dose was 29.7 units (15.6 units of total rapid insulin dose and 14.1 units of insulin glargine). At the end of pregnancy her gestational weight gain was 10.5 Kg. The patient gave birth to a female infant at 39+1 weeks' gestation with a weight of 3480 g and a length of 51 cm, appropriated for gestational age (AGA) with no perinatal complications.

34-year-old female patient, followed up in another centre, with type 1 diabetes since the age of 14, with a low level of knowledge about the disease. She has been addressed at our facility at 8 weeks gestation in an unplanned pregnancy. She is treated with MDI and isCGM sensor and has always refused insulin pump therapy, with a pre-pregnancy poor metabolic compensation (HbA1c 7.3%) with a weight of 55.5 kg and a pre-pregnancy BMI of 18.7 kg/m2. The patient was treated with rapid-acting insulin analogue glulisine, which was immediately switched to insulin lispro. It was recommended to switch to InPen ^TM to simplify the management of insulin therapy and to integrate glucose monitoring data to make it easier for patient to manage her therapy. The total daily dose was 45.8 units distributed 3.5 at breakfast, 1.5 at snack, 8 units at lunch and 8 units at dinner, with 22 units of insulin glargine U100. Pregnancy-specified target and duration of insulin action (IOB) were set up (2.0 hours). She was not able to apply CHO counting method so the dose calculator of the system mobile app was set with fixed doses. Due to low compliance, at the second trimester the time of sensor use was not optimal and ps-TIR was not sufficiently low: 68% and ps-TAR 28%, nonetheless the use of CGM helped in reducing ps-TBR 2 +2%. Dose calculator of InPen ^TM system helped patient in adjusting insulin doses at meals and correct hyperglycaemia, avoiding hypoglycaemia due to excessive correction boluses. Sensor glucose profiles helped the patient to promptly identify post-prandial hyperglycaemia dose reminders using the InPen ^TM app. Pregnancy specific TIR increased from 68% in the second trimester to 76% in third trimester and CV reduced from 36.3% in first trimester to 30.4% in third trimester (Figure 3). Especially at third trimester we assisted at an increasing need for rapid acting insulin, due to insulin resistance for pregnancy. The patient attended regular consultations with our dietician to ensure adequate CHO consumption and to limit foods with a high glycaemic index. At the end of the pregnancy, the weight gain was 12 kg since the beginning. At 37 weeks of pregnancy patient was admitted for polyhydramnios (amniotic fluid index 26), a caesarean section was performed and the patient gave birth to a male infant weight of 3680 g and a length of 52 cm, his size was large for gestational age (LGA). At 4 weeks postpartum, the mother had a stable glycaemic control.